Transition of Care Coordinator
On-siteCanal Fulton, Ohio, United States
Job Summary
Conduct post-discharge patient interviews via phone to assess needs, reconcile medication lists, and coordinate home care or medical equipment. Identify patients following inpatient discharge or ER visits, contact them within 48 hours, and track their course in Skilled Nursing Facilities until home discharge. Retrieve records from multiple hospital systems, update charts, and refer patients to long-term care management as appropriate. Work collaboratively with hospital-based nurses and staff to act as patient advocates while documenting telephone encounters. Requires RN or LPN licensure and knowledge of local hospital systems and EHR platforms.
Required Qualifications
- Registered Nurse (RN) or Licensed Practical Nurse (LPN)
- comprehensive knowledge of area hospital systems and skilled nursing facilities
- medication reconciliation
- ability to work in multiple Electronic Health Record platforms
- clinical decision making
- critical thinking for individualized patient care
- ability to teach others, including patients, peers, and staff
- self-motivated
- strong verbal and written communication skills
- flexible
- teamwork within individual offices and care management team
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