Health Home Care Coordinator - Samaritan Hospital - Full Time Days
Company: Trinity Health Corporation
Posted on: June 12, 2021
Health Home Care Coordinator - Samaritan Hospital - Full Time
Under the direction of the Supervisor of Care Coordination and
the immediate supervision of the professional nursing and social
work staff, provides follow up to progress complex discharge
planning needs through the continuum of care by securing the
clinically required placement, services and/or equipment needed.
Supports the licensed staff by completing concrete tasks necessary
to facilitate the seamless transition of patients to post-acute
care. In addition to supporting patient care coordination
activities, responsibilities include completing departmental
performance improvement activities. These activities include daily
monitoring of metrics and maintaining the daily Performance
Improvement boards. The incumbent will be responsible for
completing chart audits and reporting the findings to leadership,
working on the most complex of transitional care plans in tandem
with licensed staff. This position is responsible for assisting in
all aspects of transitional care planning under the direction of
- Quality of Life: Where career opportunities and quality of life
- Advancement: Strong orientation program, generous tuition
allowance and career development
- Work/Life: Positions and shifts to accommodate all
- We offer great Benefits including: Competitive Pay, Paid Leave.
Shift Differentials, just to name a few.
What you will do:
- Assist licensed staff with the assessment of patients and the
development and implementation of the treatment and discharge
- Collaborate with clinical care teams to review for medical
necessity and medical appropriateness of mental health and chemical
dependency services available to patients and to assist in the
development of after-care and follow-up plans, in accordance with
mental health parity guidelines.
- Makes referrals to inpatient and outpatient treatment programs
when the need is identified by licensed staff.
- Follows up on all referrals made to ensure an appropriate bed
is in place for day of discharge
- Functions as member of the interdisciplinary care team
- In collaboration with care team, makes referrals and revises as
patient's needs change.
- Provides Care Coordination to reduce fragmentation of
- Makes timely referrals under direction of licensed staff to
inpatient and outpatient treatment programs and community services
(i.e.: Capital Region Health Connections Health Home, P.S.C.C.,
county or private mental health treatment settings, SPARC services,
Dept. of Social Services, housing/shelter services, home care
agencies, domestic violence services, Primary Care Case Managers,
etc.) under the direction of licensed staff.
- Coordinates timely transfers to appropriate levels of care as
indicated by clinical needs and utilization criteria, in accordance
with interdisciplinary team assessments, hospital policy and
applicable state and federal guidelines and regulations. (i.e.:
inpatient psychiatric setting, crisis evaluation, nursing home,
home with supports, etc.)
- Assists with facilitation of patient care transitions across
the care continuum within SPHP and the patient's community of
choice, and to least restrictive most independent environment
- Develops and maintain knowledge of and understanding of
Hospital, Organization, and community resources and facilitates us
of the most appropriate level of care to conserve patient,
hospital, and payer resources.
- Documents referral information in a timely manner in accordance
with department standards, including referral date/time, contact
name/number/fax, response of referral and patient
interaction/awareness of referral outcome.
- Advocate for and facilitate discharge or transfer to
appropriate level of care, i.e.: psychiatric facility, crisis
evaluation center, housing, shelter, care facility, home with
services and supports.
- Assist the licensed staff with disposition based on safety
related to presenting issues, i(.e: CPS, APS, Detox, Domestic
Violence, Caregiver Burden, Mental Health/Substance Use Disorder,
and homelessness); in accordance with hospital, SPHP, and
regulatory guidelines; this may include pre-screening and referring
to in-hospital Detox Service for determination of inpatient or
- Faxes and photocopies medical record information to facilitate
discharge planning process and post-hospital care
- Assists in the coordination of departmental Quality Improvement
- Coordinates arrangement of durable medical equipment.
- Contacts insurance providers for authorization information as
- Makes referrals for financial assistance, entitlements and
medication assistance as requested
- Assists in facilitating transfers to facilities by checking bed
- Documents discharge planning process using Allscripts
electronic discharge planning system.
- Develops strong working relationships with various community
agencies in order to promote expedient discharges.
What you will need:
- Home Health Care Coordinator Requires Bachelor's Degree
- Two years minimum experience in a health care setting, with
acute care focus preferred.
- Working knowledge of community resources, including but not
limited to: Domestic Violence, CPS, APS, caregiver support,
substance use disorders and behavioral health services,
- Demonstrated ability to communicate effectively both written
- Ability to effectively utilize multiple EMR platforms.
- All new employees are required to undergo and pass all
applicable state and federally mandated pre-employment screening
All new employees are required to undergo and pass all
applicable state and federally mandated pre-employment screening
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of
hospitals and hundreds of health centers in 22 states. Because we
serve diverse populations, our colleagues are trained to recognize
the cultural beliefs, values, traditions, language preferences, and
health practices of the communities that we serve and to apply that
knowledge to produce positive health outcomes. We also recognize
that each of us has a different way of thinking and perceiving our
world and that these differences often lead to innovative
Trinity Health's dedication to diversity includes a unified
workforce (through training and education, recruitment, retention
and development), commitment and accountability, communication,
community partnerships, and supplier diversity.
Keywords: Trinity Health Corporation, Troy , Health Home Care Coordinator - Samaritan Hospital - Full Time Days, Other , Troy, New York
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