What are the responsibilities and job description for the Care Coordinator, Transition of Care position at Umpqua Health Management LLC?
The Role :
As the Care Coordination, Transition of Care you will be responsible for ensuring a smooth transition for patients moving between levels of care, from one healthcare setting to another, or returning home after hospitalization. This role involves working with patients, families, healthcare providers, and community resources to facilitate comprehensive care planning, education, and follow-up to improve patient outcomes and reduce readmissions
Your Impact :
- Collaborate with interdisciplinary teams to develop, implement, and monitor individualized transition of care plans.
- Assess patients and caregivers needs, preferences, and goals during care transitions.
- Coordinate and schedule follow-up appointments, tests, and procedures as required.
- Serve as the primary point of contact for patients and families during transitions, providing clear instructions and answering questions.
- Communicate relevant patient information to receiving healthcare providers to ensure continuity of care.
- Work with community resources, home health agencies, and other external partners to secure necessary services and support.
- Educate patients and their families on disease management, medication adherence, and self-care during the transition process.
- Provide resources and referrals to address social determinants of health, such as transportation, housing, or financial assistance
- Conduct post-discharge follow-up calls to assess patient status, address concerns, and reinforce care plans.
- Monitor high-risk patients closely to prevent hospital readmissions and emergency room visits.
- Document all care coordination activities in the patients electronic medical record (EMR) accurately and timely
- Participate in quality improvement initiatives aimed at enhancing the transition of care processes.
- Analyze data related to care transitions and contribute to performance improvement strategies.
- Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organizations Values.
Your Credentials :
