Registered Nurse, Transitional Care Coordinator

Job ID: J131601
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Facility: West Penn Hospital
Full/Part Time: Full time
Job Type: Regular
Posted at: Sep 27, 2018

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Description

GENERAL OVERVIEW:

As a member of the Transitional Care team, the Transitional Care Coordinator (TCC) will function as the key patient advocate as it relates to coordination of post-acute care needs across all service lines--home health, home medical equipment, home infusion, hospice and palliative care, and other health system resources.  As a hospital based resource, the TCC collaborates with all hospital departments to coordinate the most efficient transition of care for the patient.   This is a mobile experience that primarily sits at West Penn Hospital.                           

ESSENTIAL RESPONSIBILITIES:

  • Care coordination and discharge planning -- responsible for identifying all post-acute care needs for patients and collaborating with the patient's caregiver team and Case Management staff, as well as internal (Healthcare@Home) and external service providers/agencies; lead/attend daily huddles or rounds at hospital as assigned; ensure patient's prescribed plan of care is executed at time of discharge to transition care to either in-network AHN (Healthcare@Home) service providers or external partner agencies.
  • Assess patients' post-acute care needs in collaboration with interdisciplinary care team, patient, and family or caregiver.
  • Bedside education -- provide bedside visits with patients, families, and caregivers to discuss transition of care plans and services; expectation is minimum of two visits--(1) for general introduction, and (2) for confirmation of post-acute care services and specialty education as needed.
  • Referral completion -- collaborate with PTC team to ensure all required documentation for an accurate and complete referral is collected and provided to ensure seamless transition of care to post-acute service provider(s); responsible for documenting post-acute care arrangements, education, or other transitions in the appropriate software platform to promote a smooth transition of care.
  • Case management - In conjunction with Case Management staff, serve as liaison and patient advocate on difficult cases (e.g., clinical complexity, socioeconomic issues, patient safety concerns, etc.); proactively collaborate with AHN and non-AHN post-acute service providers to ensure best possible outcome for patient and other stakeholders.   
  • Infusion hookups and education.
  • Within hospital campuses, serve as liaison and customer support representative to ancillary departments, clinics, offices, etc., whose patients may benefit from coordinated post-acute care; advocate for all AHN Healthcare@Home programs and services.
  • Responsible for discipline-specific professional development, licensure, and certification.          
  • Other miscellaneous duties as assigned (e.g. participation in interdisciplinary process improvement efforts, development of documentation templates and hand-off workflows to assure safe and effective care transitions).

QUALIFICATIONS:

Minimum

  • Valid PA Registered Nurse license

Preferred

  • Bachelor’s degree
  • Post acute care experience
  • 1-3 years experience as marketing or liaison for home health, hospice, HME, or infusion
  • Valid PA driver’s license
  • Oncology background

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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