The naviHealth Transitional Care Coordinator (TCC) plays an integral role in patient journeys towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team. The Transitional Care Coordinator is responsible for identifying the appropriate Post-Acute Care (PAC) setting and evaluating a defined population for transitional needs post-discharge to improve outcomes. This ensures that efficient, smooth, and prompt health care services will be delivered to the patient across the continuum of care, beyond a single episode of care and addresses the ongoing needs of the patient. The TCC engages the hospital care team, the physicians, post-acute care providers in the home or home-like setting, the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transition of care.
Perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally-based assessment technology tools. Provides outcome targets to appropriate the audience.
Utilize naviHealth proprietary technology and industry-standard evidence-based tools for consideration of the appropriate level of care, readmission risk, and needed interventions.
Maintain nH Coordinate case documentation per established standards.
Collaborate effectively with patients’ interdisciplinary health care teams to coordinate an optimal transition plan to the most appropriate PAC setting. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc. The patient and caregiver are involved in the decision-making process to minimize service fragmentation during care transition.
Provide telephonic post-discharge support to assist the defined population of patients in meeting short and long-term goals with regards to their overall well-being. The TCC may collaborate with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care.
Partner with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers, and connect the patient to community resources and additional services.
Assess and monitor patients’ appropriateness for care setting (as indicated) according to nH Predict™, InterQual criteria and/or industry standard evidence-based criteria. Communicate with hospital case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed.
Utilize knowledge of behavioral change science and principles to guide patient/caregiver interventions.
Address end of life issues including hospice and palliative care options.
Demonstrate cultural competency with awareness and respect for diversity.
Facilitate the development of a culturally sensitive individualized transitional care plan for services that including clinical, psycho-social, and environmental needs. Monitors and evaluates the effectiveness of the plan. Make recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated.
Provide individualized evidence-based condition-specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.
Coordinate comprehensive post-discharge health care services, support programs, and referrals for community-based services
Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for process improvement.
Participate in weekly readmission and other type rounds as needed based upon opportunities.
Adhere to organizational and departmental policies and procedures.
Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws.
Perform other duties and responsibilities as required, assigned, or requested.
Active, unrestricted Registered Nurse licensure required
3 - 5 years of clinical experience required
At least 2 years of Case Management experience preferred
Patient education background, rehabilitation, and/or home health nursing experience a plus
Experience working with geriatric population preferred
Exceptional verbal and written interpersonal and communication skills
Strong problem solving, conflict resolution, and negotiating skills
Proficient with Microsoft Office applications including Word, Excel and PowerPoint
Independent problem identification/resolution and decision-making skills
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
Work Conditions and Physical Requirements
This role is performed onsite at facilities or telephonically as directed by the manager
Ability to establish a home office workspace
Ability to manipulate laptop computer (or similar hardware) between office and site settings
Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time
Ability to communicate with clients and team members including use of cellular phone or comparable communication device
Ability to sit for an extended time periods (1 - 2 hours)
Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85% of the time
Must attend 2 weeks of onsite training at Corporate Office in Brentwood, TN
Being a pioneer in post-acute management and care transitions with 19 years of experience, naviHealth is uniquely positioned to manage patients, improve clinical and financial outcomes, and share risk with payors and providers. We provide clinical service support alongside proprietary technology and advisory solutions that empower health systems, health plans and post-acute providers to navigate care episodes across the continuum, with the goal of reducing waste and improving patient outcomes.
We care about the people we serve.
We care about each other.
We care about our communities.
We embrace innovation.
We like simple.
The above statements are intended to describe the general nature and level of work performed by colleagues assigned to this job. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications. naviHealth reserves the right to amend and change responsibilities to meet business and organizational needs as necessary.
naviHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other protected status under applicable laws and will not be discriminated against on the basis of disability.