Cardinal Health Transitional Care Coordinator in San Antonio PET, Texas
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 interdisciplinarycare 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.