Transition Care Specialist

Job Number
212911
Banner Desert & Cardon Children's Medical Center
Shift
Day
Department
Banner Desert & Cardon Children's Medical Center - Discharge Planning-Hosp
Position Type
FT: Full-Time
Street Address
1400 South Dobson Rd
City & State
US-AZ-Mesa
Posting Category
Case Management

---

About Banner Desert Medical Center
Located on an 80-acre campus in Mesa, Arizona, Banner Desert Medical Center is one of Arizona's largest and most comprehensive hospitals and is recognized by U.S. News and World Report as one of Phoenix's Best Hospitals. We provide an abundance of exceptional opportunities with more than 600 licensed beds, including over 100 dedicated to children. Areas of excellence include high-risk pregnancy and neonatal care, obstetrics and gynecology, pediatrics, cardiology, oncology and emergency medicine. With 21 operating rooms, we offer a full range of surgical specialties and advanced technology that includes the daVincir Surgical System.

About Banner Cardon Children's Medical Center
If you desire to provide the best care possible to the most vulnerable patients, come to Cardon Children's Medical Center in Mesa, Ariz. Within our 248-bed, state-of-the-art facility, specially trained nurses, physicians and other clinical professionals utilize the most advanced technology - including iCare ICU monitoring and robotic surgery - to provide high quality, child-friendly, family-centered care. Our facilities feature a recently expanded 104-bed NICU, a 24-bed PICU, six pediatric ORs and a 26-bed ED. We also offer dedicated pediatric rehab, radiology, oncology and hematology capabilities. With clinical diversity, exceptional training programs and a supportive culture, this is a place where you can grow in your career as you help our very special patients.

 

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 make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.

---

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. (BLS is not required for employees working in the Insurance Division.)

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.