RN Transitional Care Coordinator (TCC) Hospice - FALCON HEALTHCARE

Interim Healthcare is a leading Regional Provider of Home Health and Hospice Services based in Texas. Our company has grown to over 35 offices in Texas and New Mexico. 

At Interim Healthcare the relationships we have with each other, and our patients are the foundation of the strong culture we have built. 

We believe in placing the patient's interests at the heart of everything we do and that’s what makes our job so rewarding. 

We understand that part of being a great Transitional Care Coordinator is spending the time to genuinely understand the patient’s story. Knowing where the patient is coming from helps us determine what they need to feel comfortable, safe, and healthy in their own home. As one of our nurses put it, “it’s an honor to be in someone’s home taking care of them.” 

At Interim Nurses don’t feel the pressure to just move through the patients, instead, nurses are empowered to invest their time in helping patients live in their homes with dignity, respect, and confidence. 

Full-Time Benefits Includes:

• Competitive wages 
• 15 Paid Days off plus 8 Holidays
• 401k with an excellent match
• Comprehensive medical, dental, and vision insurance plans
• Mileage reimbursement

General Purpose:Works collaboratively with the patient, patient's family, the acute care hospital or sub-acute facility, physician group or health plan staff to facilitate a safe and effective transition to home care.

Essential Functions:

• Assess the patient's and family caregiver's homecare needs and coordinates homehealth care services as required prior to the patient's transition home.
• Obtains necessary medical information regarding the patient's health status, currentmedications and goals of home care intervention from designated inpatient or caremanager staff.
• Acts as clinical resource to coordinate complex cases for safe and appropriate transitionto the patient's home
• Attends all Quality Improvement meetings with hospital or setting staff as required.
• Attends all required Interim Healthcare Office meetings to enhance teamcommunication, coordination of services and quality of care.
• May coordinate additional services to assist client and family during the transition, asappropriate.
• Reviews Interim Healthcare's policies and services with referred patients and/ or familycaregivers or authorized patient representative.
• Communicates with the Intake nurse and the Clinical Manager to determine staffingcapabilities.
• Communicates essential patient information to home care clinicians who will beinitiating care.
• May assist with obtaining Physician orders as required
• Responds to inquiries regarding home care services and programs to accurately identifythe needs of each patient
• May have access to and use of personal health information ("PHI") as necessary to fulfillthe above duties and responsibilities
• Performs all functions in compliance with federal, state, local law and regulation, as wellthe policies, procedures, and practice standards of Interim Healthcare.
• Assists with Insurance eligibility and authorization process, when appropriate
• Performs other duties as assigned. 

Minimum Education & Experience Requirements:

• Valid Nursing License in the State(s) in which service is provided; or valid socialwork license, as required by the state in which service is provided
• Two years nursing experience; or, two years social work experience in a medical setting
• One year of home care experience, home care intake experience or case managementexperience.
• Proof of Covid vaccination or medical exemption.