What are the responsibilities and job description for the Care Transition Specialist position at CHI Franciscan Health at Home?
The Role
As a Care Transition Specialist, you will be responsible for collaborating with care teams to facilitate timely discharges to home-based services, prioritizing patient-centered care. Your expertise in home health and hospice services will ensure continuity of care for patients transitioning from acute care to home.
Key responsibilities include:
- Partnering with providers, case managers, and social workers to identify opportunities for improvement and optimize patient care pathways.
- Guiding patients and families through the transition process, addressing barriers, and advocating for home-based services that align with their needs.
- Safeguarding patient well-being by identifying and mitigating financial and clinical risks.
- Actively participating in multidisciplinary rounds, serving as a patient advocate to ensure efficient and effective continuity of care.
