Transitional Care Nurse Coordinator

The Transitional Care Nurse Coordinator (TCNC) is responsible for coordinating patient care, ensuring efficient resource utilization, and facilitating timely discharges, with an emphasis on the Swing Bed program. Role responsibilities include utilization review, patient care coordination, quality management, and obtaining prior authorization for hospital admissions. Support is given to patients and families alike to foster clear communication from admission to discharge.

The Transitional Care Nurse Coordinator (TCNC) liaises between medical teams, insurance providers, and community resources to enhance patient support and continuity of care.

• Lead and implement the Swing Bed program.
• Coordinate patient care services, ensuring adherence to clinical guidelines and CMS care requirements.
• Conduct comprehensive patient assessments to develop individualized care plans.
• Provide ongoing patient evaluation for treatment, admission, discharge, and home planning in collaboration with Medical Staff and Nursing Staff.
• Educate patients and families on diagnoses, treatment options, and available resources.
• Advocate for patients’ rights while ensuring high-quality, cost-effective care.
• Organize outreach efforts with care providers and maintain relationships with service providers.
• Participate in quality improvement initiatives and hospital case management policy development.
• Evaluate patient satisfaction and overall quality of care provided.

• Assess all hospital referrals for appropriateness.
• Collaborate with the care team to ensure patients and families receive appropriate support.
• Work with the billing department to identify payer sources and complete prior authorizations.
• Educate staff on Medicare skilled nursing and therapy requirements.
• Identify and mitigate risks for hospital readmission.
• Maintain a referral log and facilitate communication regarding admissions and discharges.
• Stay informed of community resources and maintain materials for patient distribution.
• Act as a liaison with agencies and service providers for seamless care transitions.

• Promote effective and efficient utilization of clinical resources.
• Analyze patient records for compliance with admission, treatment, and length-of-stay criteria.
• Ensure compliance with insurance, governmental, and accrediting agency standards.
• Determine continued stay review dates and initiate appeals for denied authorizations.
• Participate in quality team meetings and present relevant data.

• Provide education and training on the Swing Bed Program for hospital staff.
• Act as a resource for discharge planning, CMS requirements, and care level guidelines.
• Support providers throughout the referral process and patient encounters.
• Offer leadership in care coordination, patient support, and program development.

• Represent the hospital at administrative functions and act as a clinical administration representative when needed.
• Perform other duties as assigned.

• Strong knowledge of CMS Swing Bed Program requirements and care guidelines.
• Experience in case management, utilization review, or discharge planning preferred.
• Excellent assessment, communication, and patient advocacy skills.
• Ability to collaborate effectively with interdisciplinary healthcare teams.
• Proficiency in documentation and care coordination within hospital settings

• Bachelor’s degree in Nursing
• Minimum of 2 years experience in case management or patient navigation, preferably in critical access or rural communities.
• A marketing and/or sales background in a healthcare setting is preferred.
• Current Colorado Registered Nurse License or compact license with the ability to obtain a Colorado Registered Nurse License.
• Working knowledge of Microsoft Office Products Working knowledge of Google Chrome & Microsoft Edge Basic computer skills
• Knowledge of Utilization Review principles
• Valid Driver’s License, vehicle insurance, and dependable transportation and able to travel within the region
• Organizational skills, good interpersonal skills
• Follow verbal instructions
• Manages stress appropriately
• Manages anger/fear/hostility/violence of others appropriately
• Works independently
• Work in confined/crowded areas
• Physical requirement- prolonged period of sitting and exert up to 10 pounds of force occasionally.