Please apply on line for this position here: https://signature-careers.com

Transitional Care Coordination is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, utilization and advocacy for options and services to meet an individual’s and family’s/caregiver’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes.

• Registered Nurse or Master of Social Work acting as a liaison between the patient, family/caregivers, clinical team, providers and third-party payers in the coordination of continued care, both for patients seen in the Health Centers as well as hospital discharges.
• Perform qualifying assessments to determine the appropriateness of patient referrals and effectively manage these referrals.
• Collaborate with Executive Director to identify priority clients and to address allocation of available time.
• Serve as a resource for discharge planners, patients and/or their families to educate them about our various services and programs.
• Accurately document all care and transition information in patient records.
• Effectively collaborate with all members of a patient’s care team, including the family and support systems.
• Advocate for patients, interacting positively with a variety of community and healthcare representatives.
• Identify barriers for care.
• Work in conjunction with Sales, Marketing and Operations Teams to accomplish objectives.
• Receive guidance from Sales Leadership regarding implementation of Signature best practices.
• Meet or exceed referral and admissions goals established by the VP of Sales and the Executive Director.
• Using Signature technology, accumulate data and provide regular updates on status and progress of activities.
• Maintain the confidentiality of all patient care information including protected health information, report known or suspected incidents of unauthorized disclosure of such information.
• Flexible schedule and regular, punctual attendance to meet with patients and caregivers to discuss and plan for services.
• Create and maintain a favorable public image of Signature Healthcare at Home. Support company mission, values and goals.
• Attend meetings and participate in committees as required.
• Attend and participate in mandatory training programs.

• Must have a current RN license in good standing or Masters’ Degree in Social Work from an accredited school of Social Work.
• Two years’ work experience in a hospital setting preferred.
• Requires exceptional communication and collaboration skills to interact with medical staff, all department staff and Health Center/Medical Home Management.
• Requires ability to problem solve effectively in complex situations.
• Must have strong assessment and goal setting skills and project management skills.
• Must be able to take the lead in a confident and competent manner in emotionally demanding situations.
• Must be knowledgeable of community resources.
• Working knowledge of prevailing Federal and State regulations guiding the profession a plus; required within 6 months of hire.
• Working knowledge of intensity/severity criteria in common use.
• Collaboration, negotiation and mediation skills; and time management and prioritization skills required.
• Familiarity with MS Office and Internet use required.
• Familiarity with HCHB or EPIC a plus and will be required within 3 months of hire.
• PRI or Screen Certification preferred and will be required after successful completion of probation status
• Must demonstrate knowledge of funding sources (third party payer contracts and requirements), health care services, human behavior dynamics, the health care delivery and financing systems, and clinical standards and outcomes.
• Must have a valid driver’s license, available insured vehicle and ability to make home visits.