Registered Nurse (RN) - Post Acute Transition Coordinator, FT, Day at Prisma Health

Inspire health. Serve with compassion. Be the difference.

Job Summary

Develops and expands patient referral sources through marketing and networking with other hospitals in the extended service area to grow and sustain patient volumes. Evaluates, monitors, facilitates and coordinates patients readiness and transfer for post-acute services (inpatient rehab, long term acute care and skilled nursing) within GHS while ensuring quality and cost-effective use of clinical resources.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's values:  Inspire health.  Serve with compassion.  Be the difference.

• Assesses and actively recruits appropriate LTACH patients from Prisma Health Acute Care Hospitals and other area hospitals. Creates and delivers presentations on all post-acute services and criteria requirements for admissions to providers, case managers, social workers, etc. Develops in conjunction with Prisma Health marketing materials and programs to aid in the growth of internal and external referrals. Actively markets the multiple post-acute care options to hospitals and providers within extended service area. Attends local, regional, and/or state case management conferences for marketing, networking, and educational purposes.

• Performs assessments to determine eligibility for post-acute services. Requires in depth understanding of admission criteria for all post-acute services including long term acute care, skilled nursing care, and inpatient rehabilitation. Assesses referrals based upon MCG criteria; skilled nursing based on CMS guidelines and Inpatient Rehab based on CMS and CARF guidelines.

• Acts as a liaison with patient, family, healthcare team and payor source to formulate placement plans as appropriate. Plans are reviewed daily to reflect patient's current needs. Maintains appropriate documentation related to patient's status regarding their transition to next level of care. Maintains open communication with providers, case managers, discharge planners, social workers, patients and families related to the patient's status and consideration for post-acute services. Maintains waiting list and communication with providers, case managers, social workers and performs ongoing assessments.

• Responsible for the transfer of the patient in a timely manner which includes transportation, provider compliance, regulatory compliance and patient and family coordination. Involves patient and family in plan for admission and in preparation for discharge beginning with day of evaluation, taking into account the patient/families cultural, ethnic, religious and spiritual needs. Identifies and anticipates potential delays in care delivery and takes appropriate actions. Integrates knowledge of payor requirements and federal/state regulations for placement along the continuum of care. Works with Utilization Management and/or Support Specialist for payor sources to complete pre-certification prior to transfer to post-acute facility. Knowledgeable of regulatory and accrediting guidelines and implements appropriately to ensure compliance.

• Participates in program evaluation, performance improvement and research for long term acute care services. Maintains data base of admissions and referrals.

• Performs other duties as assigned.

Supervisory/Management Responsibilities​

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Associate degree in Nursing. Bachelor's degree in Nursing preferred

• Experience - Three (3) years clinical bedside experience or admissions/referrals experience.

In Lieu Of

• NA

Required Certifications, Registrations, Licenses

• RN - REGISTERED NURSE - NLRN

• LTACH nursing experience- Preferred

Knowledge, Skills and Abilities

• NA

Work Shift

Day (United States of America)

Location

Roger C Peace Rehab Hosp

Facility

1010 Roger C Peace Rehabilitation Hospital

Department

10109079 Post-Acute Bed Placement

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.