Care Transitions Technician

GENERAL SUMMARY:

Conducts day-to-day activities for the clinical, psychosocial and utilization coordination of the patient's hospital experience. Proactively consults with the interdisciplinary team which includes but is not limited to hospital patient care staff, physicians, patient support and family and community resources to ensure a smooth transition for the patient through appropriate levels of care in order to facilitate quality outcomes.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Utilizes clinical skills to create and update personalized transitional care plans for patients.

3. *Performs transition planning activities at onset and throughout the patient's hospitalization.

4. *Collaborates with the patient's provider and other healthcare team members in managing the patient's length of stay and determining the appropriate level of care for transition planning.

5. Facilitates timely referrals to physicians (consults), ancillary services/programs (e.g., Pastoral Care, Nutritional Services, Diabetes Educators) for individualized assessments/interventions based on initial and ongoing assessments.

6. Facilitates patient/family participation in care planning, delivery and evaluation.

7. *Assists in identifying need for supportive counseling or post discharge extended psychosocial therapy and consults with attending Physician for referral to appropriate provider.

8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care.

9. Coordinates patient/family education efforts to promote continuity and optimize learning outcomes.

10. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship.

11. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives.

12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

13. Participates in meetings, committees and department projects as assigned.

14. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*." Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of patient care management principles and methods.

2. Knowledge of quality management and performance improvement philosophies and practices.

3. Knowledge of governmental and third-party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM).

4. Knowledge of computer hardware equipment and software applications relevant to work functions.

5. Skill in constructive problem-solving and conflict resolution.

6. Skill in responding to patient, family and visitor needs with courtesy, consideration, tact and sensitivity.

7. Ability to maintain confidentiality relevant to sensitive information.

8. Ability to communicate and cooperate with all levels of personnel, medical staff and auxiliary and ancillary departments fostering and promoting intra- and inter-departmental relationships.

9. Ability to work in a fast-paced environment related to changing patient needs including working with patients with acute, chronic and complex disease processes and those who are dying.

10. Ability to prioritize work demands and work with minimal supervision.

11. Ability to communicate effectively both verbally and in writing.

12. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.