Transitional Care Coordinator

Position Purpose Under the direction of the Transitional Care Administrator or designee, in collaboration with the Medical Director, this position is responsible to pre-screen patients for appropriateness of admission to Renown Rehabilitation Hospital, or refers to Renown Skilled Nursing Facility, Renown Home Health Care, Renown Outpatient Therapy, Wound Care, or Palliative/Hospice services according regulatory guidelines. Using discretion and independent judgment, this individual will make a preliminary determination as to whether a patient is appropriate for admission. The Transitional Care Coordinator is a member of the interdisciplinary team.

Nature And Scope

• The Transitional Care Coordinator will primarily receive orders to evaluate a patient from a physician or a member of the Renown Health care team who identifies a patient that has potential for Transitional Care in Acute Inpatient Rehabilitation, Skilled Nursing, Home Health Care, Outpatient Therapy, Wound Care, or Palliative/Hospice services. They may also receive a referral from non-Renown facilities, primary care providers, etc.
• Evaluates the appropriateness and potential for admission to facility/service based on the referral, patient current and future needs, family requests, discharge plan/support available and third party payer recommendations.
• Initiates Pre-Screen form in acute care settings as appropriate
• At Rehab Hospital, completes Rehabilitation pre-admission screening form that includes previous levels of independence, a current Functional Independence Measurement rating- as scored by review of the medical record, a review of the Rehabilitation Impairment Category, potential discharge plan and specific acute Rehabilitation needs as defined by CMS guidelines.
• Reviews information of qualifying candidates with Transitional Care Administrator or designee and then submits to the Accepting physician or Medical Director for final determination and signature
• Completes referral/pre-screen on patients not meeting acute inpatient Rehab criteria, and forwards to appropriate facility/service Intake Coordinator.
• Communicates daily with Care Coordination in acute care and Coordinators in Transitional Care settings through multiple means regarding findings
• Utilizes and Maintains documentation consistent with Renown Health's Case Management department and the Renown Facility/Service receiving referral/pre-screen.
• Educates physicians, case managers, social workers, discharge planners, caregivers, patients, and family members as to the availability and benefits of rehabilitation and Transitional Care as determined by CMS/Insurers
• Confers continuously with attending physicians, nursing staff, social workers, case managers, and transfer/Intake Coordinators.
• Demonstrates the knowledge and skills necessary to evaluate rehabilitation and Transitional Care needs, based upon physical, motor/sensory, psychosocial, and safety appropriate to the age of the patient served
• The incumbent must be able to evaluate for acute rehabilitation and Transitional Care needs through coordination with the interdisciplinary team the assessment, planning, implementation, and evaluation of adolescent, adult, and geriatric patients and families.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications: Requirements - Required and/or Preferred

Education Must have working-level knowledge of the English language, including reading, writing and speaking English.

Experience Minimum of 5 years of clinical experience in an acute care and/or rehabilitation setting. Strongly prefer clinical experience in post-acute levels of care and case management. Experience with physician and community referral development required.

License(s) Ability to obtain and maintain a State of Nevada license as an LPN, RN, PT, SLP or OT LSW, or MSW.

Certification(s) Current CPR/BLS certification required

Computer / Typing Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.