Transitional Care Coordinator
Company: Renown Healthcare
Posted on: May 20, 2019
Under the direction of the Transitional Care Administrator or
designee, in collaboration with the Medical Director, this position
is responsible to pre-screen patients for appropriateness of
admission to Renown Rehabilitation Hospital, or refers to Renown
Skilled Nursing Facility, Renown Home Health Care, Renown
Outpatient Therapy, Wound Care, or Palliative/Hospice services
according regulatory guidelines. Using discretion and independent
judgment, this individual will make a preliminary determination as
to whether a patient is appropriate for admission. The Transitional
Care Coordinator is a member of the interdisciplinary team.
Nature and Scope:
+ The Transitional Care Coordinator will primarily receive orders
to evaluate a patient from a physician or a member of the Renown
Health care team who identifies a patient that has potential for
Transitional Care in Acute Inpatient Rehabilitation, Skilled
Nursing, Home Health Care, Outpatient Therapy, Wound Care, or
Palliative/Hospice services. They may also receive a referral from
non-Renown facilities, primary care providers, etc.
+ Evaluates the appropriateness and potential for admission to
facility/service based on the referral, patient current and future
needs, family requests, discharge plan/support available and third
party payer recommendations.
+ Initiates Pre-Screen form in acute care settings as
+ At Rehab Hospital, completes Rehabilitation pre-admission
screening form that includes previous levels of independence, a
current Functional Independence Measurement rating- as scored by
review of the medical record, a review of the Rehabilitation
Impairment Category, potential discharge plan and specific acute
Rehabilitation needs as defined by CMS guidelines.
+ Reviews information of qualifying candidates with Transitional
Care Administrator or designee and then submits to the Accepting
physician or Medical Director for final determination and
+ Completes referral/pre-screen on patients not meeting acute
inpatient Rehab criteria, and forwards to appropriate
facility/service Intake Coordinator.
+ Communicates daily with Care Coordination in acute care and
Coordinators in Transitional Care settings through multiple means
+ Utilizes and Maintains documentation consistent with Renown
Health's Case Management department and the Renown Facility/Service
+ Educates physicians, case managers, social workers, discharge
planners, caregivers, patients, and family members as to the
availability and benefits of rehabilitation and Transitional Care
as determined by CMS/Insurers
+ Confers continuously with attending physicians, nursing staff,
social workers, case managers, and transfer/Intake
+ Demonstrates the knowledge and skills necessary to evaluate
rehabilitation and Transitional Care needs, based upon physical,
motor/sensory, psychosocial, and safety appropriate to the age of
the patient served
+ The incumbent must be able to evaluate for acute rehabilitation
and Transitional Care needs through coordination with the
interdisciplinary team the assessment, planning, implementation,
and evaluation of adolescent, adult, and geriatric patients and
This position does not provide patient care.
The foregoing description is not intended and should not be
construed to be an exhaustive list of all responsibilities, skills
and efforts or work conditions associated with the job. It is
intended to be an accurate reflection of the general nature and
level of the job.
Minimum Qualifications: Requirements - Required and/or
Must have working-level knowledge of the English language,
including reading, writing and speaking English.
Minimum of 5 years of clinical experience in an acute care and/or
rehabilitation setting. Strongly prefer clinical experience in
post-acute levels of care and case management. Experience with
physician and community referral development required.
Ability to obtain and maintain a State of Nevada license as an LPN,
RN, PT, SLP or OT LSW, or MSW.
Current CPR/BLS certification required
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook,
PowerPoint, Excel and Word and have the ability to use the computer
to complete online learning requirements for job-specific
competencies, access online forms and policies, complete online
benefits enrollment, etc.
Keywords: Renown Healthcare, Reno , Transitional Care Coordinator, Other , Reno, Nevada
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