Transitional Care Coord / Sales and Business Development
Hartford HealthCare at Home
 New York, NY

Excellence, Safety,

Caring, Integrity….What do you value?

Join us at Hartford

HealthCare at Home as we live our values every day. As part of Hartford

HealthCare we create a better future for healthcare in Connecticut and beyond.

By embodying these values we have become nationally respected for patient care

and most trusted for personalized coordinated care. Come be part of something


For over 115 years,

Hartford HealthCare at Home has been fulfilling our mission by enabling

individuals to achieve maximum independence, participate in their own plan of

care, and to live with dignity while receiving quality care in their own homes.

Our dedicated caregivers of HHC at Home use the latest in research and

education to develop a coordinated, consistently high standard of care for all

its customers

The Transitional

Care Coordinator works in collaboration with hospital case managers,

skilled nursing facilities, home care agencies, and physicians to coordinate

the care of patients moving from one level of care to another to insure a safe

transition across the post-acute care continuum. Serves as a bridge

between the healthcare team and the patient and/or caregivers. Provides

information and guidance to the patient and/or caregiver resulting in effective

care transitions, improved self-management skills and knowledge, and enhanced

communication between patient and healthcare team. Responsible for

building and expanding our relationships as well as identifying

opportunities to be a strategic partner, generating qualified referrals and

building new clinical initiatives.

Duties Include:

Building relationships

and trust across the continuum of practices and facilities;

Identifying patients at

risk during transition to home care (or SNF) using standard tools of assessment

Reviewing demographic

information and confirming accuracy using patient record and patient and/or

patient caregiver

Conducting “at the

bedside“ meeting with patient and/or caregiver and following patient

during the post-discharge transitional phase. Following up with the

patient to ensure that patient is following transitional plans.

Performing pre-discharge

patient and family assessment to determine understanding and acceptance of

discharge plan and orders in conjunction with discharge planning staff to

ensure a smooth transition home.

Reviewing hospital discharge

summary and medication list with patient/caregivers, and assuring the

transitional care processes are implemented by engaging patients and care

givers in health self management, including medication management.

Assessing patients'

health literacy and using teach back method as learning tool.

Initiating Personal

Health Record and emphasizing patients' early recognition of health care risks

and symptoms to achieve longer term positive outcomes and avoid adverse events,

such as re-hospitalization.

Collaborating and

communicating with Primary Care Providers and home care staff to insure

continuity of medical care through follow up appointments.

Preparing and

maintaining accurate patient records, charts and documents to support sound

medical practice.

Notifies appropriate

hospital or physician personnel when patient is having difficulty following the

transitional care program; helps to identify and remove barriers to goal

attainment, and assists with intervention as needed


communicates with VNAHC management to make sure all issues and problems are

seamlessly handled so that both the patient and the hospital/physician are

satisfied with the results and process.

Participating in case

conferences at the request of hospital and/or community agency staff.

Provides consultation to

hospital staff on community resources and home care issues

Adheres to the practice

of confidentiality (HIPAA and other state/federal regulations) regarding

patients, families, staff, and Agency.

CT licensed LPN, RN, BSN

preferred. BA, BS or previous marketing experience

Three years experience

in marketing, clinical liaison or network account management. Home care

experience preferred