Transitional Care Coordination is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, utilization and advocacy for options and services to meet an individuals and familys/caregivers comprehensive health needs through communication and available resources to promote quality cost effective outcomes. Successful outcomes cannot be achieved without specialized skills and knowledge applied throughout the process. These skills include, but are not limited to, positive relationship-building; effective written and verbal communication; negotiation; knowledge of contractual or risk arrangements; the ability to effect change, perform ongoing evaluation and critical analysis; end of life care planning and the ability to plan, organize and manage effectively. The Transitional Care Coordinator is a Registered Nurse or Master of Social Work acting as a liaison between the patient,
family/caregivers, clinical team, providers and third party payers in the coordination of continued care, both for patients seen in the
Health Centers as well as hospital discharges.
Educational Requirements/ Qualifications:
Must have a current NYS RN license in good standing or Masters Degree in Social Work from an accredited school of Social Work preferred; or obtained within 3 years of hire. . Two years experience in a hospital setting preferred.
Requires exceptional communication and collaboration skills to interact with Medical Staff, all department staff and Health
Center/Medical Home management. Requires ability to problem solve effectively in complex situations. Must have strong assessment and goal setting skills and project management skills. Must be able to take the lead in a confident and competent manner in emotionally demanding situations. Must be knowledgeable of community resources. Working knowledge of prevailing Federal and State regulations guiding the profession a plus; required within 6 months of hire. Working knowledge of intensity/severity criteria in common use.
Collaboration, negotiation and mediation skills; and time management and prioritization skills required.
Familiarity with MS Word, Excel; and Internet use required; Familiarity with Meditech a plus, and will be required within 3 months of
hire. PRI or Screen Certification preferred and will be required after successful completion of probation status. The Transitional Care
Coordinator must demonstrate knowledge of funding sources (third party payer contracts and requirements), health care services, human behavior dynamics, the health care delivery and financing systems, and clinical standards and outcomes.
Must have a valid NYS drivers license, available vehicle and ability to make home visits.