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Care Transition Coordinator, RN, Jackson Main, Care Transition Team, Full-Time, Days

Jackson Health System • Full-time • Miami, Florida, United States • 3w ago

Jackson Memorial Hospital

Department: Jackson Memorial Hospital Care Transition Team

Address: 1611 NW 12^th Ave, Miami, Florida, 33136

Shift details: Full-Time, Days, MondayFriday, 8:00AM-4:30PM

Why Jackson:

Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century. Throughout its rich and storied history, Jackson Memorial located in the heart of the City of Miami has been ground zero for some of the worlds greatest medical breakthroughs and important moments in South Florida. Weve grown into one of the nations largest public hospitals, and one of the few that is also a world-class academic medical center with a proud mission and proven success. Jackson Memorial is an accredited, tertiary teaching hospital with 1,500 licensed beds, where nearly every medical specialty is provided by some of the worlds most skilled and highly regarded multidisciplinary team of healthcare professionals.

Summary

Care Transition Coordinator is a member of the Care Transition Team responsible for determining eligibility for EDP (Early Discharge Program), for assisting in the coordination of post-acute care services/programs and for maintaining an ongoing collaboration with the interdisciplinary teams throughout Jackson Health System (JHS) facilities.
Employees in this classification perform field and office investigations relative to requests for financial and medical assistance, psychiatric treatment, social service referral, vocational rehabilitation and child protective care in county welfare or health programs.
Work may include responsibility for assisting patients and their relatives with personal or environmental problems which aggravate recovery from illness. Incumbents exercise independent judgment in evaluating information and initiating program action, preparing complete case records within the general framework of good casework techniques, existing laws, and departmental rules governing public assistance.
Work is performed under the supervision of professional superiors who review work for adherence to defined standards through personal conferences and analysis of case records, and provide assistance on unusual or difficult cases.

Responsibilities

Provides Care Transition services to patients and effective interactions with families as needed. Identifies potential patients for program inclusion through rapid recognition of clinical/social determinants that indicate patient eligibility.
Screens patient records, as assigned, using specific criteria and critical judgment, in order to identify adverse events, sub-optimal patterns or care and or utilization.
Facilitates communication and coordination between all members of the care team to coordinate appropriate discharge plans and facilitate placement program.
Demonstrates ability to work collaboratively with community resources specific to population (age, diagnosis, ethnicity, religion) served.
Attend / Coordinate patient and/or family care conferences as needed.
Maintains daily/accurate statistical data and identification of barriers to managing independent workload.
Submits statistical reports as required.
Participates on projects as required for program planning and evaluation.
Maintains current knowledge of care coordination practice including specific knowledge of the biopsychosocial issues of adult and geriatric populations.
Attends mandatory and other departmental in-services.
Provides coverage as assigned.
Participates in hospital, departmental and unit meetings.
Supports and maintains existing standards of the Public Health Trust, the department and the profession.
As needed attend rounds to discuss high LOS / complex cases and serve as a resource to assist Clinical Resources Management throughout JHS.
Respects and maintains patient confidentiality.
Maintains current knowledge of advance directives.
Assesses documents and forms for completeness. Contacts nursing homes and community agencies as needed for placement purposes.
Maintains current knowledge of the regulations, policies and procedures regarding nursing home (NH), assisted living facility (ALF), independent living facility (ILF) and Shelter placement.
Contact patients, families, and medical team as necessary for placement coordination.
Care Transition Coordinator may perform duties including but not limit to: Assist client with applications that provide social service support including, food stamps, transportation, legal services, eligibility screening for insurance benefits, Medicaid or a Jackson Prime card; meet with clients as needed, serving as the liaison for the client, family, referral source and social service agencies; Participate in the development of meaningful outcome measures that demonstrate impact on patient outcomes and behaviors.
Assess and monitor patients continued appropriateness for post-acute setting.
Follow through with unit based social worker to ensure that the plans continue to be appropriate to the patients needs.
Document and communicate the status of placements record.
Ensures the completion of transfer to the next level of care on the day of discharge.
Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).
Ability to assist others as needed.
Perform other duties and responsibilities as required, assigned, or requested to accommodate departments needs.

Experience

Generally requires 3 to 5 years of related experience.

Education

Bachelor's degree in related field is required. Nursing Education Preferred.

Credentials

American Heart Association Basic Life Support (BLS) and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment. For incumbents that requires traveling between facilities, valid Florida Drivers License is required.

Preferred Qualifications

RN License
Case Management Experience

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law

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