Transitional Care Coordinator (Jacksonville) - Judge Group

Job Description:

The Transition Care Coordinator is responsible for coordinating care for patients across the continuum to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The Transition Care Coordinator is committed to the constant pursuit of excellence in improving the health status of their patients, utilizing high level communication skills, assesses, identifies problems and outcomes, assists patients with identifying and overcoming barriers and evaluates the results. 

Key Responsibilities:

• Cultivate, maintain, and enhance relationships with clients and patients by applying tactful, direct, and sensitive interaction skills and representing the company and the Client, both within and outside the organization, in a positive, professional manner. 
• To adhere to the diversity standards and provide services without prejudice and in a manner that respects human dignity and the inherent worth of every person encountered unrestricted by considerations of race, age, religion, gender, sexual orientation, ethnicity,  culture, disability, economic status, social condition, or the nature of the health problem. Collaborates with physicians and office practices managing patients utilizing established criteria. 
• Complete initial and periodic holistic assessments for care managed population. Prioritize patients according to intensity, need and required follow up either in the office or where the patient may be located.
• Formulates and implements a care plan that addresses the patient’s identified needs by assessing the patient/family needs, issues, resources, and care goals; determining the choices available to individual patients; and educating the patient/family on the choices available. Establishes a care management plan that is mutually agreed upon by the healthcare team and the patient/family.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. 
• Partner with medical staff and leadership within hospitals, post-acute providers, physician practices, within the company and at client to identify and triage rising risk patients, reduce barriers to home discharge, improve patient progression in post-acute, and reduce readmission risk of patients’ post-discharge.
• Collaborates with the physicians, other healthcare team members including inpatient facilities, the patient’s payer, and health system administrators to facilitate across the healthcare continuum and optimize clinical and financial outcomes.
• Determines and completes appropriate referrals and serves as a liaison to providers, patients, payers and families for coordination of services. 
• Promotes patient self-management and empower patients /families to achieve maximum levels of wellness and independence by assisting them to choose lifestyle changes that will improve their health. 
• Assists the patient to identify and /or develop their support system and encourages the patient to utilize the support through motivational interviewing.
• Maintains a working knowledge of payer requirements.
• Develops collaborative working relationship with insurance case managers; negotiates on behalf of patient with third parties for cost-effective, high-quality services and to maximize the efficient use of resources. 
• Work with provider engagement teams to build partnerships with acute and post-acute providers, including regular review of performance and patient outcomes.
• Maintains databases on care managed population. Maintains accurate and timely documentation. 
• Utilizes a proactive not reactive approach to all patients who are managed by setting achievable and realistic goals, encourage self-management, oversee health maintenance follow ups such as immunizations and preventive screenings.
• Participates in regular team meetings including the Cross Continuum Team meeting, and peer review activities.
• Participates in departmental and organizational committees as applicable.
• Participates in the orientation of new employees. Acts as preceptor and promotes collaborative teamwork. 
• To be accountable for remaining current with knowledge of Acute Discharge Planning, Complex Care Management, Chronic Disease Self-Management, Patient Centered Medical Home, and Care Transitions.
• Maintains a working knowledge of and adheres to applicable federal /state regulations including but not limited to laws related to patient confidentiality, release of information, and HIPPA.

Required Qualifications:

• Valid Driver’s License Graduate of an accredited school of nursing and/or Allied Health and currently licensed in the state of employment.
• Minimum of 2 years’ experience in field and/or direct patient care.
• Good understanding of the Federal, State, and local laws and regulatory guidelines governing home health and hospice operations.
• Previous experience in Acute/ACO/Post-Acute care facility care coordination, discharge planning, social services, disease management, population health, home health, and/or post-acute care facility.

Preferred Requirements:

• Excellent communication skills and the ability to interact well with diverse individuals.
• Experience with territory management, strong presentation skills, performance management, building relationships, emphasizing excellence, negotiation, results driven, planning and execution.
• Strong understanding of customer and market dynamics, as well as transitional care best practices. Should be self-starter who requires minimal supervision.
• Proficient with Health Care IT technologies