Full-time Transitional Care Coordinator
Functional Pathways
 Loveland, OH

Functional Pathways is currently hiring at Lodge Care Center and neighboring facilities throughout the

Greater Cincinnati Area & Dayton Areas for a Full-Time Transitional Care Coordinator.

  • This is a Mobile/Remote Position with over 50% travel required*

When searching for the right employer, one should look for a company who shares the same attributes. Our own employees tell us that they like to work at Functional Pathways because we offer a family environment, ethical care, innovation, and a strong focus on values and customer service. Join us in Making a Difference in the lives we touch!

GENERAL PURPOSE OF JOB

Functional Pathways will provide a Transitional Care Coordinator (TCC) who will communicate with Facility Designee coordinating communication with resident to both plan and ensure a safe discharge.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Communicating with the resident while in the facility on a weekly basis to determine plans for a safe discharge
  • Champion the discharge plan with the MDS Coordinators and other clinical staff to make it a part of both the therapy and interdisciplinary plan of care.
  • Follow-up with the resident by phone for 30 days after discharge from the facility.
  • First call will be made within the 48 hours of resident discharge.
  • Communication can occur electronically between the care coordinator and if not resident then family/caregiver if all parties agree to this option.
  • Facility will provide a designated staff person who will work with the FP TCC related to coordination of safe discharge plans for residents in therapy service and who will be the person the FP TCC will report post- discharge telephone responses on a weekly basis.
  • Post Discharge follow-up will include the following:
  • Physician follow up visits.
  • Signs and symptoms that would indicate resident needs follow-up and could be at risk for ER or hospital readmission.
  • Medication Management.
  • Additional post-discharge follow-up items can be added at any time but must be approved by the VP Compliance Services.
  • Facility designee will review all post-discharge follow-up items with resident/caregiver and FP TCC.
  • Explanation of how the care coordination program works.
  • Make sure that any follow up physician appointments are made and understood
  • Review medication administration schedule and side effects.
  • Employ “teach back“ methodology with patient and family/caregiver to ensure that everyone has a

clear understanding of what is expected.

  • A list of questions will be developed by the facility designee and given to the FP TCC to use for weekly post- discharge follow- up calls with the resident.
  • Any post- discharge telephone response which indicates that the resident could be at risk for returning to the ER or Hospital will be reported immediately to the facility designee. The following responses could include but are not limited to:
  • Resident is not taking medication or has run out of medication and no way of getting refills.

ii. Resident is experiencing side effects of medications.

iii. Resident is experiencing warning signs identified as needing follow-up post-discharge.

iv. Resident has not kept follow-up physician appointments.

  • IF APPROPRIATE, facility designee will contact resident to make arrangements for physician visit or return to facility for additional services if within 30 day post facility discharge period.

QUALIFICATIONS

EDUCATION and/or EXPERIENCE

LANGUAGE SKILLS

  • Ability to read, analyze, and interpret common reports
  • Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
  • Ability to write articles for publication (new articles, etc.) that conform to prescribed style and format.
  • Ability to effectively present information to top management, public groups, and/or board of directors, including proposals and educational programs.

REASONING ABILITY

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Excellent communication skills. Excellent analytical and thinking skills, and a team player. Ability to work in a cubicle environment. Must be able to work under extreme pressure with limited deadlines and ability to resolve issues using facts presented. Ability to work to meet the demands of the tasks at hand. Ability to change focus with limited notice.

PC SKILLS

Comfortably uses word processing & spreadsheets for reporting; familiar with programs including calendaring, Rehab Optima, Ultipro, Healthcare Source, MedBridge, PlanSource, Word, Excel, PowerPoint, RightTrack, etc.

This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by their supervisors and/or management as required. Functional Pathways reserves the right to revise or change position description job duties and responsibilities as the need arises. This position description does not constitute a written or implied contract of employment for any term.

  • Please be aware this is a job summary, not an all-inclusive listing of the tasks and duties for this position.
  • Employment decisions and actions will be administered without regard to race, color, religion, national origin, age, veteran status, gender, disability or any other classification protected by federal, state or local law or regulation, except where any one of these is a bona fide occupational qualification. We will give full consideration to the employment of any person who is qualified to perform, with or without reasonable accommodation, the work for which application is made. This employer participates in E-Verify Este empleador participa en E-Verify.