Care Transition Associate- PAH

Company:

Position Summary

The Care Transition Associate performs a variety of patient-centered administrative tasks to support care coordination within acute care hospital hubs. This care transition work is focused on post-acute care needs for patients requiring home health, hospice, home infusion and home medical equipment. Support patients and families with their specific discharge plan and plan of care for home health and hospice referrals. The Care Transition Associate supports the work of business development by ensuring a high level of customer service and connection between our patients and referral sources increasing the volume of patients accessing care through Providence post-acute ministries, including home health, hospice/palliative care, home infusion, home medical equipment and other referrals.

This role will collaborate closely with other business development team members to build referral volumes in the hospital and develop opportunities for educational outreach that will enhance service awareness and access. Additional duties assigned may include collaboration with local Service Line leadership in essential meetings, reporting on tactical plans, training/orientation, and day-to-day support of the business development staff.

Position Specific Responsibilities

• Acts as liaison between inpatient and outpatient settings supporting post-acute service arrangements and coordination of care for patient discharge.
• Assists the Clinical Liaisons and the inpatient acute care teams in arranging care for patients discharging with Home Health, Hospice, Home Infusion and durable medical equipment (DME) care needs.
• Coordinates and arranges for admission of patients to service.
• Assesses patient appropriateness for hospice, home health, home infusion, HME services consistent with policies and procedures and admission criteria in conjunction with Clinical Liaison and patient's physician.
• Ensures services and equipment ordered are appropriate based on clinical criteria and patient diagnosis.
• Ensures required documentation is present in the patient chart.
• Obtains accurate charting and MD orders as needed to ensure appropriate insurance coverage.
• Meets with discharge planners, physician groups and other referral sources maintaining excellent customer relationships, ensuring satisfaction, providing updated materials, and informing of any updates on new or changes in services.
• Serves as a resource for inpatient care teams regarding DME documentation, testing and covered diagnosis for patients discharging from the hospital.
• Provides in-person education and consultation to patients and families regarding Home Health, Hospice, Home Infusion and HME services.
• Trains patients and/or caregivers on the operation and use of DME as needed.
• Coordinates teach times for advanced pieces of equipment.
• Coordinates delivery of equipment to the patient residence with HME and outside DME vendors as appropriate to avoid discharge delays.
• Communicates clearly to physician and provider offices verifying orders, following provider, pertinent medical and other information applicable to Home Health, Hospice, Home Infusion, and HME services clearly and concisely.
• Provides administrative support for Clinical Liaison team.
• Efficiently navigates EMR; enters patient data and appropriate documentation ensuring a high level of accuracy.
• Schedules starts of care for patients as needed.
• Responsible for providing all necessary documentation to internal and external agencies to ensure patients receive Home Health, Hospice, Home Infusion, and/or HME services ordered at discharge.
• Communicates with patient and family to verify pertinent data.
• Supports coordination of referral and reimbursement including notification of clinical teams for any follow up needed on orders and reported changes in patient condition.
• Demonstrates and maintains up to date knowledge and understanding of community resources and payer source criteria for Home Health, Hospice, Home Infusion, HME services.
• Maintains strong knowledge base on all DME equipment and supplies.
• Evaluates and collaborates to ensure all services are arranged.
• Performs other duties as assigned.

Education and/or Experience

• Required - Associate's Degree Or equivalent educ/experience
• Preferred - Coursework/Training Medical terminology.
• Preferred - Coursework/Training Health care training.
• Preferred - Coursework/Training Educational courses in healthcare.
• Education Equivalencies - High school diploma or equivalent plus three years of work experience is equivalent to the Associate's degree.
• Required - Demonstrated work experience with patients and families.
• Required - Work experience, preferably in health care setting, providing customer service and administrative support to professionals.
• Preferred - MS Word and Excel software programs.
• Preferred - Experience with Epic electronic medical records (EMR)

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Language Skills: Ability to understand, read, write, and speak English. Articulates and embraces integrated healthcare at home philosophy.
• Language Skills: Ability to develop strong, collaborative working relationships and communicate clearly and concisely.
• Language Skills: Excellent verbal and written communication skills.
• Language Skills: Strong ability to communicate clearly and sensitively in a supportive and professional manner with patient/family/caregivers and co-workers and the public.
• Computer Skills: Strong computer skills and use of electronic medical record (e.g., Epic).
• Other Skills and Abilities: Medical terminology knowledge preferred, patient chart organization, use of fax and copy machines.
• Other Skills and Abilities: Demonstrated critical thinking skills and problem solving abilities.
• Other Skills and Abilities: Demonstrates ability to effectively manage multiple competing priorities, work under stress with multiple demands by others, and get along well with others.
• Other Skills and Abilities: Ability to effectively organizing time, prioritizing multiple demands for work assignments.
• Other Skills and Abilities: Strong organizational skills and attention to detail.
• Other Skills and Abilities: Clear, concise documentation.
• Other Skills and Abilities: Work effectively as a member of a health care team.

Certifications, Licenses, and Registrations

• No Requirement

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 25 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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