Transitional Care Coordinator

ID 2022-10089
Location
Cone Health
Work Location
US-NC-Greensboro
Division : Name
Cone Health Medical Group
Department : Name
AR-Guilford Adult Health
Category
GENERAL SUPPORT
Position Sub-Category
OTHER
Position Type
Benefit Eligible (12-39 hours/week)
Employment Type
Employee
Exempt/NonExempt
Non-Exempt
FTE
0.90
Provider Schedule (specific schedule)
Monday - Thursday 8:00 AM - 5:00 PM; Friday 8:00 AM - 12:00 PM
On call Required
No

Overview

Works in conjunction with the RN Case Manager to coordinate and facilitate post-acute care for a select caseload of patients. Collaborates with and contributes to the transitional care team?s plans of care. Identifies and utilizes appropriate resources to optimize effective, efficient care plan goal achievement. Provides support to patients and families, linking them to appropriate community resources.

Responsibilities


Advocates for patient, family members and organization. Ensures patient and family are actively informed and participating in the care process. Provides counseling as needed and advocates for patient?s cultural, religious beliefs and values. Keeps care team informed of patient?s mental health status and ability to participate in decision making.

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Facilitates post discharge care and follow up. Assists the patient and care team with obtaining DME, processes home health orders/services, assists with NH/SNF placement, completes FL2s, and arranges for any additional community care services identified by the team. Participates in the daily TCC huddles as needed.

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Follows up with patients by phone to remind them of upcoming appointments and assists with the identification and removal of any barriers to keeping appointments. Schedules all appointments and routes all pertinent messages to the care team via a phone encounter.

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Tracks data in Epic for reporting purposes. Creates and manages the template for the Transitional Care Clinic and able to make last minute changes. Reviews the daily charges and ensures TCC and CPT codes are entered correctly.

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Qualifications


EDUCATION:
Required: Bachelors Degree in Social Work, Psychology, Counseling or Healthcare Related Field.

EXPERIENCE:
1-2 years healthcare related experience, Required

3-5 years of recent experience in healthcare related environment, Preferred


LICENSURE/CERTIFICATION/REGISTRY/LISTING:
REQUIRED

PREFERRED

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