Coordinator Transition Care-LPN
Job in
Oakland, Garrett County, Maryland, 21550, USA
Listing for:
Garrett Regional Medical Center
Full Time
position
Listed on 2026-02-07
Job specializations:
-
Healthcare
Healthcare Nursing
Job Description & How to Apply Below
Overview
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Comprehensively plans for targeted patient populations ensuring continuity and coordination of care. Performs resource management, discharge planning, care facilitation, barrier identification, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. Utilizes evidened based literature and best practices for readmission reduction. Effectively analyzes data collection to make effective practice decisions for the population assigned.
MINIMUM
QUALIFICATIONS EDUCATION, CERTIFICATION, AND/OR LICENSURE
Current unencumbered licensure with the WV Board of Practical Nursing, or appropriate state board where services will be provided, as a practical nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
Obtain certification in Basic Life Support within 30 days of hire date.
PREFERRED QUALIFICATIONS EXPERIENCE
Three (3) years of experience preferred.
CORE DUTIES AND RESPONSIBILITIES
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and EducationAddresses/resolves system problems impeding diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care.Collaborates with all members of the Multidisciplinary Team to facilitate the transition process for designated caseload.Coordinates with healthcare team for patient and family education including treatment plan, medication and ongoing wellness planning.Monitors the patient s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.Provides education as needed to staff, physicians, and patients for transitional planning needs.Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and transitional plan changes.Seeks consultation from appropriate disciplines/departments for ongoing care planning.Refers cases and issues to appropriate personnel, in compliance with department procedures and follows up as indicated.Follows-up with the patient according to established clinical program protocols and time frames to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the ongoing needs of the patient.Initiates and facilities referrals to transitional services which may include but are not limited to home health care, hospice, medical equipment and supplies.Documents relevant care transition planning information in the medical record according to Department standards.Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiativesPHYSICAL REQUIREMENTS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to…
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