Transition Care Specialist

Job Number
203021
Banner - University Medical Center Phoenix
Shift
Day
Department
Banner - University Medical Center Phoenix - Discharge Planning-Hosp
Position Type
FT: Full-Time
Street Address
1111 East McDowell Rd
City & State
US-AZ-Phoenix
Posting Category
Social Services
New Grad
No

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Transition Care Specialist:

 

This position facilitates the safe and timely transition from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides onsite or telephonic discharge arrangements to post-acute and community services.

Processes and facilitates the timely discharge/transfer of patients from hospital care to identified post-acute setting. Works collaboratively with care coordination team members to identify any barriers to a safe discharge, and works with patient/family to provide clear communication regarding discharge plan.

 

MINIMUM REQUIREMENT:   BASIC LIFE SUPPORT (BLS) CERTIFICATION

  • You may register online. Cost is approximately $25.
  • BLS must be a “Healthcare Provider Course.” Banner requires skills performance demonstration to be acceptable. Online only certifications will not qualify.
  • The following three companies meet these Banner standards:
    • American Heart Association (AHA)
    • American Health and Safety Institute (ASHI)
    • Red Cross

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About Banner - University Medical Center Phoenix
Banner - University Medical Center Phoenix is a nationally recognized academic medical center. The world-class hospital is focused on coordinated clinical care, expanded research activities and nurturing future generations of highly trained medical professionals. Our commitment to nursing excellence has enabled us to achieve Magnet™ recognition by the American Nurses Credentialing Center. The Phoenix campus, long known for excellent patient care, has over 730 licensed beds, a number of unique specialty units and is the new home for medical discoveries, thanks to our collaboration with the University of Arizona College of Medicine - Phoenix. Additionally, the campus responsibilities include fully integrated multi-specialty and sub-specialty clinics, and with a new $400 million campus investment, a new patient tower and 2 new clinic buildings will be built.

 

Truven-2013
Stage7-2013

About Banner Health
Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to change the way care is provided. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.

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Job Summary

This position facilitates the safe and timely transition of clients from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care or community program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides on-site or telephonic discharge arrangements to post-acute and community services.

 

Essential Functions

  • Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting. Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.

 

  • Facilitates/ implements the care plan with proposed interventions in collaboration with healthcare team. Collaborates with all members of the healthcare team to implement, manage and communicate the transition of care arrangements.

 

  • Participates in performance improvement projects, Banner initiatives and performs data collection for measurement of projects as assigned.

 

  • Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.

 

  • Assist and support patients and families in making appropriate arrangements for the post-acute plan. Performs follow-up calls to patients and providers as indicated and report any concerns to leadership.

 

  • Serves as an intermediary when providing community resources to patients, caregiver, and families. Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipated discharge date and potential care settings.

 

  • Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.

 

 

Minimum Qualifications

A Bachelors degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.

Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid, long term care or other applicable resources/services. Must demonstrate effective communication and customer service skills, human relation skills and time management skills. Must be able to work flexible hours and work weekends on rotation.BLS required.

Preferred Qualifications

Previous experience in health care service setting, interacting with patients and families, usually obtained through work in social services, as a licensed practical nurse or in a discharge planning setting.

Additional related education and/or experience preferred.