The Care Transition Coordinator plays a pivotal role in facilitating seamless transitions for patients from healthcare facilities to home health or hospice care. This position is responsible for evaluating patient eligibility, coordinating care plans, and ensuring all services are arranged in alignment with agency protocols and patient needs.
Requirements
- Achieve monthly personal production goals and Medicare-certified admission targets for assigned locations.
- Implement weekly, monthly, and quarterly strategies to increase market share within assigned facilities.
- Evaluate patients and physician orders for home care eligibility in accordance with Right of Choice guidelines.
- Conduct face-to-face patient transitions to provide agency education and identify the primary care physician responsible for the plan of care.
- Present identified patient needs to the Executive Director to obtain branch approval and acceptance.
- Coordinate transfer orders and ancillary services (e.g., DME, infusion).
- Ensure all patient needs identified by the referral source are documented and addressed by the agency upon acceptance.
- Collaborate with the Executive Director and Clinical Director to promote growth by aligning team efforts with the needs and expectations of referral sources and patients.
- Perform sales administration duties including BOA expense entry, adherence to BOA policies and procedures, payroll timesheet submission, participation in weekly 3LS meetings, submission of PTO requests, and attendance at required sales calls and company-provided in-services.
- Educate patients on the importance of post-discharge physician appointments, obtaining necessary prescriptions prior to discharge, and understanding medication regimens, pharmacy use, and delivery methods.
- Act as liaison between the agency and healthcare providers for newly referred patients and existing patients transferred to hospitals from home health services.
- Notify discharge planning of active patients transferred from home health to a facility.
- Provide follow-up feedback to the case management team on readmission status and non-admitdecisions based on agency-provided information.
- Maintain patient confidentiality in accordance with applicable laws and agency policies.
- Demonstrate knowledge of agency services, competitive advantages, specialty programs, and Medicare guidelines.
- Educate medical professionals using appropriate tools and literature.
