• Job Description

  Req#: 2025-31421

  It's fun to work in a company where people truly BELIEVE in what they're doing!

  Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work! Be it through providing healing, eradicating loneliness, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job.

  Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, financial stewardship, leadership and care.

  
  The Transition Coach - RN ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute and post-acute care environments in accordance with company standards and federal, state, and local standards, guidelines, and regulations.

  Essential Activities and Tasks

  Care Transition Coordination - 55%

  • Coaches patients for self-management of health and wellness priorities.

  • Collaborates with the care teams to provide discharge and transition education to patients.

  • Collaborates with discharge planners and other key team members to manage transition of care activities and communicate vital information.

  • Works in partnership with acute and post-acute care team to follow patient through care continuum and reconnect to healthcare team.

  • Identifies safe transition barriers for the patient and collaborates in comprehensive care plan development.

  • Identifies and coordinates patient access to necessary services, including primary care physician identification, potential home health or hospice services, community resources, and long-term care supports.

  • Coach for self-management of health and wellness priorities.

  • Collaborates with care team to provide discharge/transition education.

  • Identifies resources and long term services and support to assist patients in remaining independent in the community.

  Operations Management and Administration - 20%

  • Identifies high risk patients utilizing a standardized stratification process.

  • Reviews completed medication reconciliation.

  • Utilizes motivational interviewing techniques with patient to improve patient engagement and successful implementation of care planning strategies.

  • Facilitates post-hospitalization appointment scheduling and ensures appointments are met.

  • Ensures timely documentation of patient encounters.

  • Collects data, tracks outcomes, and supports strategic planning initiatives.

  • Participates in quality improvement initiatives.

  Quality, Compliance, and Risk Management - 15%

  • Maintains current and accurate records through use of computers and/or other documentation in accordance with company standards and federal, state, and local standards, guidelines, and regulations.

  • Maintains knowledge of requirements of regulatory agencies, accrediting bodies, and third party payers.

  • Identifies and implements best practices for transitions of care.

  • Understands and easily accesses Electronic Medical Records (EMR) systems within our organization and computer systems in other healthcare facilities.

  • Obtains and reviews pertinent demographic and medical information for writing up referrals so that appropriate care can be initiated upon physician recommendation.

  Relationship Management - 10%

  • Establishes and maintains positive working relationships with all key customers (physicians, extended care facilities, patients, families, and interdisciplinary team members).

  
  All other duties as assigned.

  
  Qualifications

  Education

  • Bachelor of Science in Nursing (BSN) preferred.

  • Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN) required.

  Experience

  • Two years experience in a hospital or senior living post-acute care setting required.

  • Strong knowledge of the full continuum of care and the eligibility requirements for home health, hospice, skilled nursing, and assisted living required.

  • Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), and the internet required.

  • Proficiency with an electronic medical records (EMR) system required.

  Other Requirements

  • Must be able to read, write, speak, and understand the English language.

  • Must possess a valid driver's license and acceptable driving record. Must be insurable under professional liability and crime coverage policies as specified by insurance carrier underwriting standards.

  Working Conditions and Special Requirements

  • Sitting - Up to 8 hours/day

  • Standing Up to 4 hours/day

  • Walking - Up to 6 hours/day

  • Lifting, transferring, pushing or pulling residents/patients or equipment/supplies. - Up to 50 pounds

  • Driving - Up to 6 hours/day

  • Work weekends, evenings, and holidays. - As scheduled

  • On-call availability - As needed

  • Subject to patients/patients with various disease processes. - Occasional

  • May be exposed to infectious waste, disease, conditions, etc. including exposure to the AIDS and Hepatitis B viruses. - Work day

  • Risk Category for Exposure to Bloodborne Diseases - I

• About the company

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