Transitional Care Professional - Registered Nurse - Your Health Organization

GENERAL DESCRIPTION
The Transitional Care Professional position plays a crucial role in facilitating a smooth transition for patients from hospitals, rehabilitation centers and skilled nursing facilities to their homes by providing comprehensive care coordination and support. The Transitional Care Professional plays a vital role in enhancing the patient experience and reducing hospital readmissions.
AREAS OF RESPONSIBILITY
A successful Transitional Care Professional will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.
The following is a list of essential functions, which may be subject to change at any time and without notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).
Patient Engagement and Guidance
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Visit the Company’s referrals and established patients within assigned facilities.
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Establish trust and rapport with patients to assist them in making informed decisions regarding their health duringtheir stay in the facility.
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Provide guidance and feedback to patients based on recommendations from the care team regarding their care.
Transitional Care Coordination
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Ensure a seamless transition for patients returning home by arranging the necessary services, such as homehealth, outpatient rehab, and follow-up care with the Company’s providers and support staff.
Appointment Scheduling and Coordination
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Schedule and coordinate all essential visits including those with the Company’s primary care provider, virtualprovider, specialists, pharmacist, social worker, health coach, community health worker, visiting nurse, etc.
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Facilitate effective communication between healthcare professionals involved in the patient’s care.
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Ensure patient and family adherence to the plan of care.
Administrative and Communication
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Patient Communication: Interact with patients via phone, email, patient portal, telephone, text, in person, etc. togather necessary information.
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Customer Service: Provide exceptional customer service to patients, exhibiting a compassionate and empatheticattitude and a patient-centered approach to care. Address patient concerns, inquires, and complaintsprofessionally and promptly, striving to meet patient needs and ensure their satisfaction.
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Administrative Functions: Perform general administrative tasks and support other staff as needed. Utilize thecompany’s software systems to enhance patient care and staff productivity.
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Must be available during normal work hours (unless previously approved by direct supervisor). Additionalhours may be required to complete normal business functions and/or projects.
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Participate in coaching calls.
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Perform other duties as requested or required, in the sole discretion of the Company.
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MISSION EXPECTATIONS
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Take responsibility for own work in completing tasks. Assist others so that the resources, assistance orsupport is provided to achieve success in their daily work.
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Communicate, endorse, and demonstrate SC House Calls’ mission, vision and values.
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Prompt and regular attendance.
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Adhere to standards of behavior, dress code including name tag and approved uniform, personnel departmentand company policies.
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Attend in-services and meetings on a regular basis.
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Promote a culture of outstanding customer service at all times.
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Must be available during normal work hours (unless previously approved by direct supervisor). Additional hoursmay be required to complete normal business functions and/or projects.
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Must possess the ability to deal tactfully with patients, employees, management, visitors, government agencies,and the general public and maintain an open-door policy for all employees.
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Must possess the ability to make independent decisions when circumstances warrant.
WORK ENVIRONMENT
The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of the job:
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May be exposed to housekeeping cleaning agents and chemicals, humidity, hot equipment, and/or noise.
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May be exposed to infections, communicable diseases, odors, bloodborne pathogens, excreta and hazardousmaterials.
COMPLIANCE WITH POLICIES AND PROCEDURES
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Comply with all federal, state and local laws and regulations.
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Knowledge of and compliance with Patient’s Bill of Rights.
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Must be knowledgeable of Medicare guidelines, applicable laws and regulations, and SC House Calls policy andprocedures.
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Adhere to SC House Calls’ Code of Conduct / Ethics.
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Must exercise a high degree of confidentiality regarding patients, personnel and the company.
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HIPAA compliant.
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Promote a culture of compliance.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.
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Must be able to lift, reach, bend, push, pull, use repetitive hand motions, walk and carry simultaneously.
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Must be able to withstand reaching, stooping, bending, kneeling, and crouching; walking and standing for periodsof time; lifting up to fifty (50) pounds.
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Must be in good general health and demonstrate emotional stability.
QUALIFICATIONS
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Must be a Certified Medical Assistant. Licensed nurse preferred. Certification or license must bein good standing with the appropriate board/issuer.
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A minimum of three (3) years clinical experience preferred.
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Demonstrated ability to supervise and direct professional and administrative personnel.
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Ability to read and communicate effectively.
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Strong written and verbal skills.
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Basic computer knowledge.
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Ability to manage and demonstrate effective leadership skills.
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Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
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Ability to foster a cooperative work environment.
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Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
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Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with anautomobile that is insured in accordance with state and/or organizational requirements and is in good workingorder.
I have received, reviewed and understand the requirements of this job, and agree that I can perform the requirements of this position. I accept the position and agree to perform in accordance with established policies and procedures, and all Federal, State and local laws, regulations, codes and accepted professional standards and principles that apply. I understand that if I require a reasonable accommodation to perform any essential function of my job, I will clearly communicate that to Human Resources. Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you are required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar or is a logical assignment of the position, in the sole discretion of SC House Calls. This job description does not constitute a contract of guaranteed employment for any period of time. I understand that my employment is at-will and that I can be terminated at any time, with or without notice or cause.