RN Patient Transition Coordinator
Core
Coordinates seamless transitions for patients moving from acute and long-term care to home care services, managing referrals and clinical reviews.
Role type
Patient Transition Coordinator (RN)
Builds
Home care service transitions and patient care plans
Domain
Healthcare / Home Health
Deliverable
client delivery
Required skills
Clinical review, Medicare/Insurance coverage criteria knowledge, patient and family interviewing, data entry, care coordination, policy process support
Preferred skills
Home health experience, case management experience, clinical social work knowledge
Technologies
Computer systems for data entry and retrieval
Responsibilities
Coordinate services for patient transitions from acute/long-term care to home care; perform clinical review of referral data; confer with patients, families, and medical staff; enter and retrieve data in computer systems; assist in updating policies and procedures; conduct patient interviews to verify demographics and discuss care plans