Centra Health
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Specialist Care Transitions-FT Days
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Centra Health 1 week ago Be among the first 25 applicants Join to apply for the
Specialist Care Transitions-FT Days
role at
Centra Health Job Description
Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community. Job Description
Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.
Responsibilities
Coordinates patient care from admission to discharge in collaboration with RN and clinical team
Conducts a comprehensive patient/family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needs
Identifies any barriers and provides clarity to determine realistic goals for the treatment plan
Demonstrates understanding of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan
Collaborates with IDT clinical team to develop transition of care plan
Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays
Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system
Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
Works with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issues
Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner
Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days
Coordinates and provides hand off to other post-acute providers
Contributes to the overall LOS
Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)
Identifies patients requiring crisis intervention and acts as soon as possible to resolve the issue(s) and prevent barriers to patient flow
Qualifications
Required Education: Bachelors Degree in Social Work, Social Services, or Health Promotions
Required Experience: Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines
Preferred Experience: Working knowledge of D/C planning, post acute services, or Medicare regulations
Required Certifications and Licensures: Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.
Preferred Certifications and Licensures: CCM Certification Care Coordination and Transitions Management Certification Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Hospitals and Health Care Referrals increase your chances of interviewing at Centra Health by 2x Sign in to set job alerts for “Care Specialist” roles.
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Fulltime Benefits Weekends Only - Palliative Care PA/NP
Lynchburg, VA $49,000.00-$53,000.00 3 days ago Office Assistant - Helms School of Government
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Care Transitions Coordinator Home Health-LPN PTA COTA,
Care Transitions Coordinator Home Health-LPN PTA COTA
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
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Specialist Care Transitions-FT Days
role at
Centra Health 1 week ago Be among the first 25 applicants Join to apply for the
Specialist Care Transitions-FT Days
role at
Centra Health Job Description
Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community. Job Description
Care transitions non-RN is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.
Responsibilities
Coordinates patient care from admission to discharge in collaboration with RN and clinical team
Conducts a comprehensive patient/family assessment to ensure appropriate referrals to address psychosocial and socioeconomic needs
Identifies any barriers and provides clarity to determine realistic goals for the treatment plan
Demonstrates understanding of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan
Collaborates with IDT clinical team to develop transition of care plan
Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays
Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system
Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
Works with the IDT clinical team to understand the patient's utilization plan, appropriateness of continued hospitalization, observation status, length of stay and quality issues
Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner
Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days
Coordinates and provides hand off to other post-acute providers
Contributes to the overall LOS
Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)
Identifies patients requiring crisis intervention and acts as soon as possible to resolve the issue(s) and prevent barriers to patient flow
Qualifications
Required Education: Bachelors Degree in Social Work, Social Services, or Health Promotions
Required Experience: Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines
Preferred Experience: Working knowledge of D/C planning, post acute services, or Medicare regulations
Required Certifications and Licensures: Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.
Preferred Certifications and Licensures: CCM Certification Care Coordination and Transitions Management Certification Seniority level
Seniority level Entry level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Hospitals and Health Care Referrals increase your chances of interviewing at Centra Health by 2x Sign in to set job alerts for “Care Specialist” roles.
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Entry-Level Healthcare Position - Training Provided
Fulltime Benefits Weekends Only - Palliative Care PA/NP
Lynchburg, VA $49,000.00-$53,000.00 3 days ago Office Assistant - Helms School of Government
Paramedic Critical Care - LGH/ Full Time Variable Shifts
Administrative Assistant for Internal Affairs
Paramedic Critical Care - LGH/Part Time Variable Shifts
Paramedic Critical Care - BMH/Full Time Nights
Care Transitions Coordinator Home Health-LPN PTA COTA,
Care Transitions Coordinator Home Health-LPN PTA COTA
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr