Overview
Job Summary
Assists with coordination of transition of care from hospital to home for patients identified as high-risk for
readmission. The coordinator will assist with screening high-risk patients and coordinating the discharge
plan. This role will assist the RN Navigator and Manager with other duties related to transitions team
coordination.
Job Responsibilities
• Assist with daily screening of admissions to help identify high-risk patients.
• Chart review and/or patient interviews to assess current needs or barriers.
• Scheduling a hospital follow up appointment for all patients identified to be followed by Transition
of Care team. This includes but not limited to: specialist appointment scheduling, PCP follow-up
scheduling– calling their office to schedule appointment, calling the patient to notify them of their
appointment if they are already discharged.
• Documenting the hospital follow up appointment in Epic on the AVS and communicating post discharge follow-up plan with patient and/or representative.
• Assist patients with setting up MyChart as needed for continued communication with transitions
team.
• Sending referrals to additional agencies as needed i.e. home health, behavioral health, etc.
• Coordinate with Case Management and Nursing teams to address social drivers of health
challenges prior to discharge i.e. transportation, food, etc.
• Assisting Social Work with getting financial aid paperwork done for uninsured patients and followup post-discharge for completion.
• Tracking/data collection/metric as determined by manager.
• Coordination with disease specific quality coordinators as needed for patient specific needs i.e.
sepsis, HF, AMI
Specifications
Experience
Minimum Required
Preferred/Desired
Education
Minimum Required
Preferred/Desired
Special Skills
Minimum Required