Transitional Care Associate
Core
Facilitate safe and timely discharge/transfer of patients from acute hospital care to post-acute settings (skilled nursing, rehab, home care, hospice) and coordinate community resources.
Role type
Transitional Care Associate (Clinical Care)
Builds
Discharge plans and post-acute care transitions for patients and families
Domain
Healthcare / Clinical Care / Social Work
Deliverable
client delivery
Required skills
Discharge planning, care coordination, Medicare/Medicaid knowledge, patient/family communication, data documentation, resource navigation
Preferred skills
Healthcare service experience, social work background, licensed practical nurse experience
Technologies
Electronic medical records (implied by documentation)
Responsibilities
Process and facilitate timely discharge/transfer 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; Maintain knowledge of government benefits.