RN Patient Transition Coordinator Homecare

RN Patient Transition Coordinator Homecare

Newport News, Virginia

$75,000.00–$85,000.00

Performs coordination of services to provide a seamless transition from acute and long‑term care to Home Care. Elements required include data collection and clinical review of all referrals; determination of referral acceptance based on established criteria and collaboration with Home Care team members; attaining and remaining knowledgeable and current on Medicare/Insurance reimbursement and basic coverage criteria, and on service lines and products;

and conferencing with patients, families, discharge planners, physicians, medical staff and others to coordinate and facilitate transition and services. Works closely with facility care management/discharge planners to identify potential referrals for Home Care Services. Provides exceptional customer service and serves as the “face” of RHCD to all contacts by telephone, in person, and via electronic media. Provides leadership to and supervision for the RHCD Patient Transition Coordinators.

• Performs coordination of services to provide a seamless transition from acute and long‑term care to Home Care. Completes clinical review of data collected and accurately determines appropriateness and acceptance of referrals based on established criteria. Coordinates services and dissemination of information, and facilitates transfer of referral to another agency for referrals declined by RHCD. Performs follow‑up and continues communication with all parties until referral is complete and/or services are provided or canceled.
• Serves as an information resource for all RHCD services including contact information, coverage criteria, availability of services and alternatives to RHCD services when appropriate. Provides exceptional customer service by tone of voice, willingness to help, using clinical knowledge to collect complete and appropriate data for referrals, and to field phone calls/pages/in‑person inquiries efficiently and appropriately.
• Accurately and efficiently enters data into and retrieves data from various computer systems. Accurately and efficiently records data to specified RHCD forms.
• Works closely with care management team/discharge planners to identify potential referrals for RHCD services.
• Builds comprehensive knowledge base, and continuously works toward remaining knowledgeable and current on Medicare/Insurance information and regulations, RHCD products and services, and community resources. Assists Central Intake Manager with review, updating, and creation of policies, procedures, and processes as needed.
• Performs patient interviews or family conferences to inform of ordered services, verify demographics, answer any questions, discuss insurance coverage as appropriate, discuss any special circumstances or barriers to a safe transition or care at home as appropriate.

• Program Graduate, Nursing (Required)
• Associate’s Degree, Sociology/Social Work/Nursing (Required)
• Bachelor’s Degree, Sociology/Social Work/Nursing (Preferred)

• 1 year Nursing experience (Required)
• Home health experience (Preferred)
• Case management and health care delivery experience (Preferred)

• Registered Nurse (RN) – Virginia Department of Health Professions (VDHP) (Required)
• CPR/BLS Certification – American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) within 30 days (Required)
• Clinical Social Worker (Preferred)

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