Job Description

HCA FACILITY PARTNERING WITH OCTIVA HEALTHCARE

JOB SUMMARY

The Transition Specialist plays an integral role in optimizing patients’ recovery journeys. The transition Specialist is the hospital program liaison and the patient’s initial point of contact with Octiva Healthcare. The Transition Specialist engages the PAC inter-disciplinary care team and collaborates effectively with the patients’ health care teams to establish an optimal discharge. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Transition Specialist is responsible for ensuring efficient, smooth, and prompt transitions of care.

RESPONSIBILITIES

• Hospital facing relationship builder with patients’ health care teams to establish an optimal discharge. The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.
• Onboard and intake of patients into Octiva Healthcare post-acute care pathways
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed.
• Attend patient/family care conferences.
• Assess and monitor patients’ continued appropriateness for home discharge or other home care needs
• Coordinate virtual introduction to program medical oversight, nurse call team, and mobile medical assistants.
• Support new delegated contract start-up to ensure experienced staff work with new contracts.
• Manage assigned caseload in an efficiently and effectively utilizing time management skills.
• Enter timely and accurate documentation into EMR and CRM
• Daily review of census and identification of barriers to managing independent workload and ability to assist others.
• Review monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager, as needed, to assist with the identification of opportunities for improvement.
• Adhere to organizational and departmental policies and procedures.
• Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws.
• Perform other duties and responsibilities as required, assigned, or requested.

QUALIFICATIONS

• MA or CNA preferred
• Experience working with geriatric population preferred
• Exceptional verbal and written interpersonal and communication skills
• Strong problem solving, conflict resolution, and negotiating skills
• Proficient with Microsoft Office applications including Word, Excel and PowerPoint
• Independent problem identification/resolution and decision-making skills
• Detail-oriented
• Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
• Team player

WORK CONDITIONS AND PHYSICAL REQUIREMENTS

• Ability to establish a home office workspace

• Ability to manipulate laptop computer (or similar hardware) between office and site settings

• Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time

• Ability to communicate with clients and team members including use of cellular phone and video care platforms

• Ability to remain stationary for extended time periods (1 - 2 hours)

• Travel requirements

• Ability to mobilize outside of the facility within an assigned local or regional market/area, including car transport, up to 25% of the time

OTHER DUTIES

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.