Description COVENANT HEALTHCARE US:MI:SAGINAW VARIABLE SHIFT FULL TIME BENEFITED Summary: The Transitional Care Tech (TCT) position has numerous important responsibilities that impact the delivery of patient care and outcomes. The TCT is the primary interface to Covenant HealthCare s referral sources and is responsible for maintaining these professional relationships, while playing an integral role in the patient s journey towards better well-being by serving as the communication link between Case Management (CRM), the patient, and their ambulatory interdisciplinary health care team. The TCT is responsible for identifying the appropriate Post-Acute Care (PAC) setting and evaluating a defined population for transitional needs post-discharge to improve outcomes. This insures that efficient, smooth, and prompt health care services will be delivered to the patient across the continuum of care, beyond a single episode of care and addresses the ongoing needs of the patient. The TCT engages the hospital care team, the physicians, post-acute care providers in the home or home-like setting, the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transition of care. The TCT demonstrates excellent customer service performance in the his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant and the commitment to Extraordinary Care for Every Generation. Responsibilities: The TCT role is performed onsite at facilities or telephonically as directed by the CRM Manager Services are provided in a collaborative process that assess, plans, implements, coordinates, monitors and evaluates options and services required to meet the patient s post-acute health needs, using communication and available resources to promote quality, cost-effective outcomes May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally-based assessment technology tools Collaborates effectively with the patient s interdisciplinary health care team, which includes physicians, health plan UM/CM Nurse, hospital discharge planners, community providers, etc. to assess, coordinate, and monitor an optimal transition plan to the most appropriate PAC setting Serves as a liaison between Covenant HealthCare and the patients/caregivers as well as community providers. Development of Covenant HealthCare preferred network for post-acute providers, including Home Health, SNF, and Acute Rehab, LTC Responsibility for supporting all transitional care and post-acute services in a defined area Administrative lead and point of contact with post-acute providers Building and enhancing relationships with Post-Acute providers including providing completing educational visits with patients to market Covenant post-acute services Coordinating and facilitating the transition of patients from acute care to post-acute care Collaborates in the development of tracking metrics/reports for the preferred provider network to include quality, customer service, and cost data Development and achievement of metrics of success in the areas of quality, patient safety, customer service, cost, LOS, re-admissions, and other post-acute transition areas Knowledge of resources for patients in coordinating transitions between doctor's office, acute hospitalization, and post-acute resources is a plus May collaborate with other care team members such as home health providers for telephonic follow up and coordinate care, as indicated Partners with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers, and to connect the patient to community resources and additional services In collaboration with CRM-Case Management coordinates comprehensive post discharge health care services, support programs, and referrals for community-based services Maintains case documentation per established standards Review readmission reports and other reports as needed to assist with the identification of opportunities for process improvement IT HAS BEEN DETERMINED THAT COVENANT HEALTHCARE CANNOT PROVIDE A LATEX SAFE OR LATEX FREE WORK ENVIRONMENT AT ANY OF ITS FACILITIES. UNFORTUNATELY, THAT MEANS THAT ANY INDIVIDUAL, INCLUDING AN APPLICANT OR AN EMPLOYEE, IS LIKELY TO BE EXPOSED TO LATEX WHILE ON COVENANT S PREMISES.
Covenant HealthCare is an equal opportunity employer.
Employer's Job# 11512
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