Care Transitions Coordinator
The Care Transitions Coordinator is a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for home health or hospice services, directly communicating with and assessing the patient to improve the patient’s transition from the inpatient to the home setting; and (2) developing the referral relationships of the agency within the community, in accordance with Amedisys policies and procedures.
1) After a patient has selected Amedisys as his or her health care provider, the Care Transitions Coordinator visits the patient onsite to review the physician order, assess the patient’s clinical needs and gather clinical information. The Care Transitions Coordinator uses a Point of Service computer application to collect referred patient data onsite and transmit it to the agency. The Care Transitions Coordinator also facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to home.
2) The Care Transitions Coordinator is also responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health plan of care.
3) Face to Face documentation must also be noted in Point of Service computer and communicated to appropriate care center.
4) The Care Transitions Coordinator is also responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.
5) The Care Transitions Coordinator has a strong focus to help reduce ACH 30 day -hospitalizations.
1. RN strongly preferred. LPN, PT, OT are considered in some cases (with a current, active, unencumbered license in the state of service);
2. 1+ years previous experience assisting patients through the continuum of care and the transition from hospital to home care.
3. Current CPR certification
4. Competent organizational skills;
5. Ability to handle stressful situations/deadlines;
6. Excellent oral/written communication and interpersonal skills;
7. Must demonstrate the ability to communicate effectively with all members of the health care team;
8. Demonstrates desire to work in a marketing role; and
9. Ability to forecasts needs and set priorities.
10. Proficient in computer-based skills. Must have working knowledge and practical application experience with general office computer systems (i.e. Microsoft Excel), internet, email, desktop navigation.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, genetic predisposition or carrier status or any other legally protected characteristic.
Amedisys is a leading home health and hospice care company focused on bringing home the continuum of care. We deliver personalized home health and hospice care to thousands of patients and their families, in the comfort of their own homes.
We focus on delivering the care that’s best for our patients, whether that is home-based recovery and rehabilitation after an operation or injury, care focused on empowering them to manage a chronic disease, palliative care for those with a terminal illness, or hospice care at the end of life.
Taking care of your loved ones as we would our own – that is the philosophy Amedisys was built on. This simple concept, coupled with our core beliefs, has guided Amedisys’ growth in becoming one of the nation’s leading health care companies focused on bringing home the continuum of care.
Amedisys embodies the heart, mind and soul of health care, including the way we contribute to society at large and the communities we serve. As an organization whose business it is to take care of people, we believe strongly in the power of community service and contributing to medical science to provide better care of our aging population for generations to come.
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