Transitional Care Coordinator

MedStar Health is looking for a Transitional Care Coordinator to join our team at Washington Hospital Center!

The Transitional Care Coordinator coordinates patient care and discharge planning across the continuum under the auspices of a provider's prescribed plan of care, national guidelines, and within the scope of case management practice. In this role, you will educate and provide information and support to patients in order to guide and facilitate understanding of treatment plans prescribed by licensed independent practitioners and/or within scope of nursing/ social work /respiratory therapy practice. You will also oversee, direct, and provide holistic, culturally competent and evidence-based care. Additional responsibilities include monitoring patient outcomes and participating in quality improvement activities, contributing to and collaborating with health care team members to positively impact patient outcomes and patient experiences. You will be recognized as a professional role model, and Case Management Care Co-ordination readmission prevention expert who promotes a professional environment that supports nursing/social work/ respiratory therapy excellence and collaborative shared decision­ making. 

Join one of the largest healthcare systems in the Baltimore-Washington metro region, also recognized as one of the "Healthiest Maryland Businesses". Apply today and learn how MedStar Health can be your next great career move! 

 
Primary Duties: 

• Handles patient assessment, education, discharge planning, and development of a post acute care plan. Arranges and coordinates post-acute services, and direct follow-up, and monitoring patients’ progress relative to their post-acute plan. Analyzes services and resources necessary to effectively prevent readmission and/or respond to the readmitted patients’ episode of care encompassing the 30 day period post discharge from an inpatient stay. Monitors patient progress, goal attainment and patient experience feedback to evaluate the effectiveness of care. Ensures plan of care changes are communicated to patient, family, and team. 

•  Works within the interdisciplinary team throughout the continuum of care to develop and manage the plan of care for the patient, assisting patient/family with scheduling of ancillary testing and follow-up appointments; completing risk assessment screening and education regarding resources available to the patient and family/significant caregiver; and planning for continuing care such as, but not limited to, patient and community services, community outreach resources, home care, palliative, and hospice services as necessary. Contributes to development of internal case management guidelines/pathways. 

•  Provides patient education such as initial and follow-up continuing education related to specific disease process, associated treatment modality, management, and agreed plan of care for patient and family; and is available as a resources to assist in the provision of community education and outreach development. Acts as a liaison between patients, families, the health care team, community resources and other facilities to coordinate the provision of post acute care; and as a patient advocate to help identify and eliminate barriers to care. Ensures patients' referral process and transition into specialty services are timely and efficient, anticipates patient and family needs throughout the continuum of care. Explores and connects patients with appropriate resources, health care and support services within MedStar Washington Hospital Center, at other external facilities, and in their communities for timely diagnosis, treatment, and survivorship. 

•  Monitors patient outcomes and utilizes quality improvement activities and strategies that support quality patient care and optimizes outcomes in an interdisciplinary care environment and consistent with patient and family wishes. 

•  Researches cause of all readmissions, reevaluates discharge plan, and works with the patient and family/support on needs of renewed discharge plan. Maintains a working knowledge of available clinical trials that might be appropriate to the patient population. Collaborates with research coordinators and/or principle investigators to ensure adherence to research protocols. 

Qualifications:  

• Bachelor’s degree in Nursing OR Master’s Degree in Social Work OR Associate’s degree in Respiratory Therapy required. 

• 3-4 years of progressively more responsible patient education and services coordination experience required. 

• RN (Registered Nurse) State or Compact Licensure in District of Columbia  

         OR LICSW (Licensed Independent Clinical Social Worker) in District of Columbia  

         OR RCP (Licensed Respiratory Care Practitioner) AND RRT (Registered Respiratory Therapist) by the National                   Board for Respiratory Care/NRBC required. 

• Professional Case Management certification preferred.