Transitional Care Coordinator

Job Description

University of Toledo Physicians' mission is to improve the human condition through excellence in patient care and medical discovery. Representing more than 200 physicians, UT Physicians are leaders in clinical care, research and education of the future physicians, providing care in a wide range of medical specialties from the most complex diagnoses and treatments to primary care for the entire family. The primary site of inpatient care services is at the University of Toledo Medical Center, but many of our physicians’ practice at hospitals and medical offices throughout the region.

University of Toledo Physicians offers competitive pay and benefits including: 403B, Pension, health and tuition waiver at UT.

Position Summary

Responsible for the development and execution of care coordination activities for an identified population of patients attributed to ambulatory practices.

Essential Job Functions And Accountabilities

• Complete follow-up calls for patients of University of Toledo primary care providers discharging from all area Emergency Departments (ED).
• Assist in overall reduction of avoidable Emergency Department visits.
• Review ED discharge instructions including patient medications; communicate with providers as needed for clarification.
• Identify and assist in addressing barriers to care, including but not limited to social determinants of health.
• Connect patients to specialists and care team members through referral management.
• Educate patients on office hours and utilize “Call Us First” education.
• Document succinctly and communicate with Primary Care Providers.
• Link patients back to Primary Care for continuity of care and appointment follow-up.
• Communicate with RN Transitional Care Managers and RN Longitudinal Care Managers as indicated.
• Communicate with clinics, specialties, hospital, and community involved in patient care, patient satisfaction, quality improvement, and operations as indicated.
• Participate in program, department, and clinic team meetings as indicated.
• Identify and build upon the assets and strengths of the patient and their support system, colleagues, and entire interdisciplinary care team.
• Maintain a professional, collaborative, and productive relationship with the patient and their support system, colleagues, and entire interdisciplinary care team.
• Effectively utilize all tools and resources available to support care coordination proficiently.
• Participate in quality improvement projects as indicated.
• The Transitional Care Coordinator works with a team of healthcare professionals and will require the flexibility to shift responsibilities as necessary.
• Other duties as required.
  
  

Required Qualifications

Education:

• Graduate of an accredited Licensed Practical Nursing Program
  
  

Skills:

• Experience in acute or sub-acute health care setting, or ambulatory care practice environment required.
• Excellent written and verbal communication skills required.
• Excellent interpersonal skills required.
• Demonstrated ability to manage client-provider relationships required.
• Demonstrated ability to meet deadlines required.
  
  

Years of Experience:

• A minimum of 1 year
  
  

License and/or Certification:

• Current unencumbered license to practice as a Licensed Practical Nurse in Ohio.
  
  

Preferred Qualifications

Education:

• Graduate of an accredited Registered Nursing program
• BSN or appropriate allied health degree from an accredited academic program.
  
  

Skills:

• Transitional care coordination experience preferred.
• Quality improvement process experience preferred.
• Epic EMR and CliniSync Notify experience preferred.
  
  

Years of Experience: 3 years of applicable experience.

License and/or Certification:

• Current unencumbered license to practice as a Licensed Practical Nurse in Ohio and Michigan.
  
  

The above list of duties is intended to describe the general nature and level of work performed by people assigned to this classification. It is not intended to be construed as an exhaustive list of duties performed by the people so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct and control the work of employees under his/her supervision.

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity or gender expression, age, disability, military or veteran status, height, weight, familial or marital status, or genetics.

Equal Opportunity Employer/Drug-Free Workplace

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