Onsite Transition Coordinator at UPMC

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Full Time

Start Date

Immediate

Expiry Date

20 Mar, 26

Salary

0.0

Posted On

20 Dec, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Care Coordination, Patient Education, Interdisciplinary Teamwork, Discharge Planning, Case Management, Communication Skills, Clinical Knowledge, Medication Review, Health Management, Quality of Care, Patient-Centered Approach, Problem Solving, Documentation, Collaboration, Assessment Skills, Crisis Management

Industry

Hospitals and Health Care

Description

Located in Cumberland, MD - UPMC Western Maryland is full of opportunities for those looking to take the next step in their career! We are currently hiring a full-time Onsite Transition Coordinator to support our Population Health Department. This is a full-time, Monday - Friday dayshift position that will work with patients who have no PCP or are at high risk for readmission on their transition of care. The Transition Coordinator coordinates care with an interdisciplinary team approach to improving care transition from hospital to home or post-acute care. Completes education during and after hospitalization, prepares and reinforces patient education and materials ensuring the discharge of a well-prepared patient. Facilitates patient activated and self-management through a patient centered approach to reduce care fragmentation and medical errors. Additionally, designed to help patients and their care givers understand post discharge care plan, with follow-up call designed to sustain education and promote continuity of care across the transitions. Responsibilities: Reconcile treatment plan and medical record documentation with National Guidelines, if any discrepancies discovered collaborate with medical team to ascertain resolution. Requests home care order on all patients admitted with COPD, CHF, on new anticoagulant therapy, and other patients as deemed appropriate. Identifies potential quality of care concerns and never events and refers to Health Plan Quality Management Department. Complete an overall review of medical record to determine admission diagnoses, barriers, start discharge plan, assess educational needs. Introduces educational materials and interviews patient and caregivers on admission. On discharge any unclear discharge instruction will be clarified with physician. Responsible for identification of appropriate patients for case management, behavioral health referrals, health management referrals and palliative care. On discharge will reinforce hospital discharge instructions and any other applicable education materials and complete a final review with patient and family if appropriate. Participates in hospital multidisciplinary team meeting, initiates referral to Health Plan discharge planner in complex cases when appropriate, and requests and participates in Health Plan integrated team meeting when appropriate. Coordinate post discharge appointments with physicians, specialist, and other Health Care personnel. Consults with the Health Plan Medical Director on an as-needed basis to seek advisement on difficult cases, strategize on high utilizers, and request Health Plan Medical Director to Attending MD consult when necessary. Completes tools and list of supports necessary to support the discharge care plan, including educational materials, hospital discharge instructions, hospital medical condition specific sheets, medication education sheets etc. Identifies and tracks readmissions within 30 days and completes readmission survey. All education is complete during hospital stay and documented in the medical record, Health Plan documentation system, and educational documents. Performs a post discharge call within 2 days after discharge. During the call reinforce previous teaching concentrating on health status diagnosis, medications, appointment and test, home services, symptom response plan. Coordinates a follow-up call with Pharmacist to further review medications. Collaborates with Health Plan Pharmacist for medication review when appropriate. Review with patient and family and needs for durable medical equipment at home. Assist with identifying coverage, coordinate with DME liaison to get arranged, and education patient and family if appropriate purpose of equipment. Responsible for coordinating with the hospital staff discharge planning. Review medical record to obtain principal diagnoses and any other secondary diagnoses. Collect and print necessary training material and educate patient and family if appropriate. Education is done on admission and reinforced during hospitalization. Review with patient and family any pending test or studies at time of discharge. Will have a working and clinical knowledge of the available ancillary services and is able to clearly articulate an alternative plan to the attending physician. Conduct medication review on admission and at discharge. A complete assessment of the patient's ability to comply with current and new medication orders. If barriers identified, will work with facility care team and Health Plan case management to identify possible solutions. A daily review of the medications will be conducted to identify new medication orders. Review with patient and family if appropriate symptom response plan and what to do if a problem arises. Completes transition assessment on identified patient's and works with Health Plan Case Management team to identify opportunities to prevent readmissions and completes interventions as appropriate. Educates patient on Health Plan and hospital outpatient programs. Bachelor's degree in nursing preferred. Five years of experience in clinical, case management, home care, discharge planning, and/or disease management required. Three years of experience in a managed care environment, utilization, case, or disease management preferred. Ability to interact with physicians and other health care professionals in a professional manner required. Computer proficiency required. Experience with Microsoft Office preferred. Excellent verbal and written communication and interpersonal skills required. Licensure, Certifications, and Clearances: Manager Certification preferred. CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire. Automotive Insurance Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR) Driver's License Registered Nurse (RN) *Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state. UPMC is an Equal Opportunity Employer/Disability/Veteran

Responsibilities

The Onsite Transition Coordinator is responsible for coordinating care transitions from hospital to home, ensuring patients understand their discharge plans and follow-up care. They also facilitate education for patients and caregivers, track readmissions, and collaborate with healthcare teams.