• Care Transition Coordinator - Hospice

    Location : Facility Name
    Saint Mary's Hospice of Northern Nevada
    Requisition ID
    Location : Postal Code
    Position Type
    Work Schedule
    Normal (Based on FT, PT, PRN)
    Location : City
    Location : State/Province
  • Overview

    The Care Transition Coordinator's primary responsibility is to facilitate a seamless transition for patients discharging from a facility setting to the care of an LHC Group agency for post acute care needs. Included and aligned within this responsibility is the understanding and implementation of company market development initiatives and their role in growth as we focus on serving more patients and delivering exceptional care. The CTC will verify home health orders, assess the care required, and ensure continuity of care and the agency's ability to meet the needs of the patient. This clinical liaison position will assess each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs the CTC will begin best practice intervention and education to improve patient outcomes and promote patient self management. The CTC will implement rehospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate between healthcare providers during all phases of transition from the facility into the home.


    LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home. Hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home. More hospitals, physicians and families choose LHC Group, because we are united by a single, shared purpose: It's all about helping people. 

    Additional Details

    Essential Funcitons

    • Successfully executes a weekly, monthly, and quarterly strategy to increase market share through key account development including prospecting|diversification and call frequency|routing. Plans activity to maximize territory coverage of both existing and prospective accounts
    • Responsible for achievement of admission goals|expectations as established at hire or at review of annual agency budget goals
    • Assists the LHC Group agency with the preparation for accepting care of the patient post discharge from the hospital
    • Coordinates other services for the patient with ancillary service providers (DME|Infusion)
    • Ensures the availability of a attending physician to follow the patients care in the home or the transfer of primary care to the hospice medical director
    • Assists the Administrator with execution of contracts for facility based services for hospice patients
    • Explains hospice services and agency procedures to the patient and his|her family members
    • Involves the family|caregivers in the educational process and assesses post-discharge educational|coaching needs
    • Knowledgeable about state specific admission criteria and timelines for admission
    • Monitors the status of all patients receiving Respite or General Inpatient Care and facilitate the communication between the agency|hospital|physician
    • Participate in bi-weekly IDG meetings, as necessary to give an update regarding accounts, customer needs, and progress towards agency growth strategies
    • Participates in weekly one-on-one meetings with Administrator
    • Responsible for the initial medication reconciliation with appropriate hand off and communication to visiting staff
    • Schedules a follow-up phone call to the FCC in the system 48 hours post admit
    • Serves as a liaison between the LHC Group agency, the facility care setting and the referring physician
    • Serves as an educational resource for hospital staff and physicians regarding the hospice benefit and related regulations, including, consulting with hospital staff or physicians regarding an individual patients suitability for hospice benefit provided there is NO contact with the patient or the patients family members prior to the referral to hospice
    • Visits and communicates with the patient in the hospital to obtain necessary information to facilitate the transfer
    • All other duties as assigned


    Education and Experience

    • Must have one year hospice experience or one year of hospital case management experience

    License Requirements

    • Must have current RN or LPN or SW licensure in state of practice

    Skill Requirements

    • Excellent organizational skills.
    • Excellent verbal and written communication skills.
    • Must have thorough understanding of hospice qualifying criteria and coverage guidelines.
    • Proficent computer skills.
    • Current CPR, driver's license, valid vehicle insurance and access to a dependable vehicle, or public transportation.


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