Transition of Care Partner - Peekskill
2 weeks ago
Job summary
Sun River Health is seeking a full-time Transition of Care Coordinator to join our team in Peekskill, NY.We provide preventative care and outreach for varying at risk populations. Facilitates follow-up for patients who have had a recent discharge,
including but not limited to: inpatient hospital discharges, emergency room visits,
postpartum units, skilled nursing and rehabilitation facilities. They are responsible
for appointment setting, referring patients to appropriate agencies,
specialty providers and community resources.
- Facilitates bidirectional information exchange with hospital and primary care provider/team
- Performs rounds to hospital where indicated to meet with patients admission personnel case managers discharge planners others
- Performs outreach follow-up for patients who have had a recent discharge including but not limited to: inpatient hospital discharges emergency room visits postpartum units skilled nursing and rehabilitation facilities
- Responsible for appointment setting referring patients to appropriate agencies specialty providers and community resources < li >Obtain hospital records ensures records are received scanned e-faxed in ecw identifies barriers interdisciplinary collaboration proposes strategies improve toc identifies needed followup tests indicates via appropriate emr documentation Coordinates patient documentation such as hospital discharge papers medication lists visit summaries that will prepare the patient healthcare provider visit Obtains consultant reports medical record releases consents Accountable managing outreach schedule patient followup appointment setting providing care coordination both internal external stakeholders Evaluates assists patient overcoming barriers obtaining necessary appointments medical care Screens patients factors influencing social determinants health initiates referrals using appropriate resources Consults transition of care team seeks clarification when needed identifies escalates encounters require complex care or medical triage Participates development implementation patents Transition of Care Plan coordinating nursing meet established goals Identifies refers maintains continuity care patents requiring highrisk management collaborating licensed clinical staff Monitor coordinates treatment plans as indicated licensed clinical personnel Identifies refers maintains continuity care patents requiring highrisk management collaborating licensed clinical staff
Job description
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