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Care Transition Coordinator


This is a Contract position in Grand Blanc, MI posted June 8, 2021.

Ascension at Home – Together with Compassus Associates: Please apply via Workday


The Care Transition Coordinator is responsible for modeling the 3 Company values of Compassion, Integrity, and Excellence, and for promoting the Compassus philosophy, using the 6 Pillars of success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Care Transition Coordinator navigates getting patients into the right care at the right time.

  • Position-specific Responsibilities
  • Regularly meets with physicians in the hospital to discuss specific patients:
    • Documents interaction in salesforce.
    • Gives guidance and provides understanding of post-acute service support.
    • Ensures continuity of care as a priority
    • Communicates data sets to clinicians (e.g., Care Delivery Scorecard, predictive analytics, prognostic scores).
  • Grand rounds attendance:
    • Networking
  • Hospital case managers (rounding or interactions in step with hospital):
    • High-risk patient review.
    • Aligns with cadence of patient review – prognostication, data analytics, risk-profiling.
  • Collaborates with existing palliative care in hospital:
    • Supports transition to home health, palliative care, infusion, and hospice services.
    • Educates on post-acute  benefits and Medicare/ payer coverage.
  • Develops genuine collegial relationships with other hospital  professionals:
    • Identifies times and meets regularly with clinicians to problem solve, review cases.
  • Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative Preferences:
    • Acquires knowledge to complete POLST/MOLST/DNR, as needed.
    • Understands disease trajectories; explains risk/benefits of treatments.
  • Communication:
    • Understands steps to explaining disease trajectory (recovery, chronic or terminal trajectories) and knows steps to offering a difficult prognosis.
    • Identifies barriers that patients/families have towards understanding disease trajectories and prognosis.
    • Understands how to interact with difficult patients/families.
    • Identifies steps to having a successful family meeting.
  • Defines Surrogate Decision-maker:
    • Develops communication skills to support patients/families with difficult discussions or differing points of views.
    • Understands roles and responsibilities of the surrogate decision-maker especially around admission/POC.
  • Maintains documentation of patient/family goals of care:
    • Know how to complete a GOC visit using Compassus tools.
  • Maintains current list of admission coordinators for each healthcare service line.
  • Aligns recommendations between patient/family and Primary care team:
    • Identifies patient preferences/needs.
    • Identify patient’s post-acute care needs
    • Confirm the level of care most appropriate for the patient – right care, right time.
    • Facilitate ‘transition to home’ planning including assessing post-discharge needs and developing and implementing transition to home plan
  • Sets patient-centered goals and facilitating transitions:
    • Understands how to identify patient/family specific treatment goals.
  • Facilitates discharge to appropriate post-acute setting; works with local teams to ensure smooth transition and home “ready.” (i.e. equipment and medications delivered, etc.)
  • Coordinates patient care by obtaining H&P, physician orders, hospital records and face to face documentation in a timely manner.
  • Verifies patient demographic information is correct.
  • Coordinates organization of transfer orders; educates patient on home care orders and home care services.
  • Identifies primary care physician to follow the plan of care.
  • Conducts follow-up on re-hospitalized home health patients.
  • Participates in home health re-hospitalization mitigation strategies – be a member of the strategy team.
  • Develops ability to understand and digest claims data, use of predictive analytics.
  • Ensures excellent customer service to maintain and grow the business in the identified key accounts.
  • Consistently works to improve personal knowledge and sales skills to become of greater value to our most important customers and to the organization.
  • Meets or exceeds assigned quotas, thereby maintaining and constantly improving the HH’s competitive position.
  • Performs other duties as assigned.

KNOWLEDGE AND SKILLS   To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Registered Nurse in the state of employment and two to three years’ nursing experience required. Bachelor’s degree and experience in healthcare marketing preferred. Hospital and/or long-term care clinical experience highly preferred.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percentage.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, colleagues, investors, and external parties. Strong written and verbal communications.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, or schedule form.

Computer Skills

Proficiency in Microsoft Office Suite.

Other Qualifications

Strong organizational and time management skills. Due to the nature of patient care some flexibility of schedule will be required to meet patient and customer needs. . Local travel required.

Certifications, Licenses and Registrations

A valid driver’s license and auto liability insurance.

Other Skills and Abilities

Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by a colleague to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the colleague is regularly required to use hands to finger, handle, or feel; talk and hear. The colleague frequently is required to stand, sit, and reach with hands and arms. The colleague is occasionally required to walk; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The colleague must frequently lift and/or move more than 25 pounds. Specific vision abilities required by this job include close vision.

WORK ENVIRONMENT The work environment characteristics described here are representative of those a colleague encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

There will be possible exposure to infectious diseases through working with clinical caregivers.  The noise level in the work environment is usually quiet.