RN Transitional Care Coordinator-Parma

Job description

RN Transitional Care Coordinator-Parma - ( 260003LR ) Description A Brief Overview: Ensures appropriate next site of care for patient using evidence-based decision support tools. The Transitional Care Coordinator (TCC) collaborates with all members of a patient's care team, including the family and support systems, to enhance the patient experience and ready the patient for the next site of care. The TCC develops and modifies a patient's post-acute care plan, identifies any barriers for follow-up care, brings in specialty in-hospital consultations as needed (nutrition, social work, therapy, etc.), and helps facilitate the provider hand-off to the next level of care. What You Will Do: - Completes assessment including patient’s previous level of functioning, connection to hospital and community based resources, existing supports, SDOH. Documents comprehensive plan and facilitates necessary referrals as needed. 30% - Communicates and collaborates with the larger team with a multidisciplinary approach. 10% - Provides updates to medical team and nursing of patients plan of care and plan for the stay, discharge or movement to alternative site including but not limited to home care, SNF,...