Transitional Care Associate
Core
Facilitate safe and timely discharge of patients from acute hospital care to post-acute settings like skilled nursing, home health, or rehabilitation.
Role type
Transitional Care Associate (Clinical Care)
Builds
Discharge plans and care transitions for patients moving to alternative levels of care
Domain
Healthcare / Clinical Care / Case Management
Deliverable
client delivery
Required skills
Discharge planning, care coordination, Medicare/Medicaid knowledge, patient advocacy, data documentation, resource navigation
Preferred skills
Social work background, Licensed Practical Nurse (LPN) experience, discharge planning experience
Technologies
Electronic Medical Records (implied via documentation)
Responsibilities
Process and facilitate timely discharge/transfer of clients to post-acute settings; Collaborate with healthcare team to implement care plans; Document interventions and discharge plans in medical records; Assist patients/families in arranging post-acute care; Perform follow-up calls to patients and providers; Serve as intermediary for community resources.
Seniority
Individual Contributor, entry-to-mid level