Transitional Care Coordinator
*naviHealth is seeking candidates in Youngstown, OH.
naviHealth is the result of over a decade of dedicated visionary leaders and innovative organizations challenging the status quo for PAC management solutions. We do healthcare differently and we are changing healthcare one patient at a time. How might you ask? By hiring talented clinicians, engineers, analysts, and healthcare leaders to create and utilize cutting edge technology to provide the patient with the best level of care for the right amount of time.
Why Is This Role Critical?
The naviHealth Transitional Care Coordinator (TCC) plays an integral role in the patient’s journey towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team. The Care Coordinator is responsible for identifying the appropriate Post-Acute Care (PAC) setting and evaluating a defined population for transitional needs post-discharge to improve outcomes. This ensures that efficient, smooth, and prompt health care services will be delivered to the patient across the continuum of care, beyond a single episode of care and addresses the ongoing needs of the patient. The TCC engages the hospital care team, the physicians, post-acute care providers in the home or home-like setting, the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transition of care.
- This role is performed onsite at facilities or telephonically as directed by the manager.
- Services are provided in a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services required to meet the patient’s post-acute health needs, using communication and available resources to promote quality, cost-effective outcomes.
- May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally-based assessment technology tools. Provides outcome targets to appropriate audience.
- Utilizes naviHealth proprietary technology and industry standard evidence-based tools for consideration of appropriate level of care, readmission risk and needed interventions.
- Maintains nH Coordinate case documentation per established standards.
- Collaborates effectively with the patient’s interdisciplinary health care team to coordinate an optimal transition plan to the most appropriate PAC setting. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc. The patient and caregiver are involved in the decision making process to minimize service fragmentation during care transition.
- Provides telephonic post-discharge support to assist the defined population of patients in meeting short and long-term goals with regards to their overall well-being. The TCC may collaborate with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care.
- The TCC partners with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers and to connect the patient to community resources and additional services.
- Assess and monitors patient’s appropriateness for care setting (as indicated) according to nH Predict™, InterQual criteria and/or industry standard evidence-based criteria. Communicates with Hospital Case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed.
- Utilizes knowledge of behavioral change science and principles to guide patient/caregiver interventions.
- Addresses end of life issues including hospice and palliative care options.
- Practices cultural competency with awareness and respect for diversity.
- Facilitates the development of a culturally sensitive individualized transitional care plan for services that including clinical, psycho-social, and environmental needs. Monitors and evaluates the effectiveness of the plan. Makes recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated.
- Provides individualized evidence based condition specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.
- Coordinates comprehensive post discharge health care services, support programs, and referrals for community-based services
- Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for process improvement.
- Participates in weekly readmission and other type rounds as needed based upon opportunities.
- Adheres to organizational and departmental policies and procedures.
- Maintains confidentiality of all PHI information in compliance with HIPPA, federal and state regulations and laws.
- Keeps current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies and benefits)
- Pursue multi-state licensure to meet business needs
- Adheres to organizational departmental policies and procedures
- Adheres to all local, state and federal regulatory policies and procedures
- Must promote a positive attitude and work environment
- Attends naviHealth meetings as requested
- Performs all other duties as assigned
- Holds as confidential the patient’s protected health information as required by applicable laws, regulations, or agency/institution procedures.
- Registered Nurse with current, active unrestricted licensure required
- 5 years of clinical experience.
- Case Management experience with CCM preferred.
- Patient education background, rehabilitation, SNF and/or home
health nursing experience a plus.
- Experience working with geriatric population preferred.
- Excellent documentation and technology skills required
- Self-starter with the ability to prioritize daily work load.
- Strong interpersonal and communication skills (both verbal and written).
- CMS and managed care knowledge preferred.
NaviHealth partners with health plans, health systems and post-acute providers
to manage the entire continuum of post-acute care. We utilize evidence-based protocols to optimize care and bundled payment methodologies to align all stakeholders. The result: optimized care and outcomes, reduced inpatient days, reduced hospital readmissions, and increased patient satisfaction.
NaviHealth ™ is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.
Cardinal Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.