RN or LSW - Onsite Care Transition Coordinator - State of MS University of MS Medical Center
Healthcare - Nursing
148 Co Rd 405
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To support and coordinate care transitions during a hospital event. Ensure adequate and appropriate care transitions from a hospital setting to the next level of care. Interacting with members, families, care givers and care teams at the bedside. Facilitate care transitions from the hospital to a post-acute inpatient setting to include Skilled Nursing Facility (SNF); Acute Inpatient Rehab (AIR or IRF); Long Term Care hospitals (LTAC); or directly from the hospital to the member's home or back into a community setting or to the provider practice.
To anticipate, prepare and support hospitals in transitioning UHC members from a hospital event in a way that drives positive experiences for the member and provider; results in efficient and stress-free coordination and ensures the appropriate level of care to meet the clinical needs of the UHC member.
Bridge gaps in discharge coordination and facilitate hard hand offs to post-acute networks and community clinical programs. Ensure smooth internal and external handoffs and partnerships across the enterprise and to support a member-centric approach to care transitions within the local market.
* Work onsite at assigned hospital(s) during business hours Monday - Friday * Identify any UHC member in an outpatient observation bed or an inpatient medical / surgical setting (excluding maternity members) that may require post-acute care to include either a secondary level of care (SNF, AIR, LTAC) or home health support or services to avoid an unnecessary readmission * Engage with the hospital care transition or discharge planning teams and the member / family or caregiver to prepare for transitions and assist in facilitating the discharge plan * Identify and direct care to in-network providers of post-acute services when available to meet the needs of the member * Request gap exceptions when an in-network provider is not accessible to meet the member's needs * Utilize tools, such as Health@Scale, to identify and direct members to in-network providers with experience and quality outcomes specific to the members needs and in the member's preferred geographic location * Initiate DME / HME, Infusion or Dialysis, home health, palliative care and hospice providers to support the member's continued needs after discharge * Facilitate discharge medications and remove barriers to obtaining quickly, if not prior to discharge within 24 hrs of discharge for follow up within 7 calendar days of discharge * Review and recommend transportation solutions * Coordinate clinical information necessary to facilitate medical necessity determinations * Coordinate P2P with hospital attending physicians and UCS Medical Directors, if necessary to facilitate the most appropriate medical determinations for an AIR or LTAC requests * Coordinate discharge summary to the next continuum, i.e. AIR, LTAC, SNF, CTP, WPC, Disease Management Programs or an ACO, PCP or Specialist Providers * Enter timely and accurate discharge date and disposition of member into case management tool * Notify Clinical Programs such as CTP. TTS, PAT, or House Call practitioners of discharge disposition * This role requires you to stand for periods of time and walk distances between hospitals regularly
* Current unrestricted RN or LSW license in state of residence * 3 years clinical experience * Ability to be credentialed at assigned hospital and meet all hospital occupational health requirements (drug screening, licensure and immunizations) * Access to reliable transportation and ability to travel to hospital location for primary work site * Data entry experience into case management systems * Experience and intermediate skill level working with laptop for daily work (navigating Windows environment) * Smartphone capabilities * Experience with discharge planning * DC planning from an inpatient to lower level of care
* Case management, community care or resource coordination * Experience with transitional care services
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