Care Transition Coordinator

Jackson Health System

Department: Jackson Memorial Hospital - Care Transition Team
Address: 1611 NW 12th Ave, Miami, Florida, 33136
Shift details: Full-Time, Days

Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world’s top medical providers for all levels of care, no matter if it’s for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine.

Here, the best people come together to deliver Jackson’s mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do.

Care Transition Coordinator is a member of the Care Transition Team responsible for determining eligibility for EDP (Early Discharge Program), for assisting in the coordination of post-acute care services/programs and for maintaining an ongoing collaboration with the interdisciplinary teams throughout Jackson Health System (JHS) facilities. Employees in this classification perform field and office investigations relative to requests for financial and medical assistance, psychiatric treatment, social service referral, vocational rehabilitation and child protective care in county welfare or health programs.

Work may include responsibility for assisting patients and their relatives with personal or environmental problems which aggravate recovery from illness. Incumbents exercise independent judgment in evaluating information and initiating program action, preparing complete case records within the general framework of good casework techniques, existing laws, and departmental rules governing public assistance. Work is performed under the supervision of professional superiors who review work for adherence to defined standards through personal conferences and analysis of case records and provide assistance on unusual or difficult cases.

• Provides Care Transition services to patients and effective interactions with families as needed.
• Identifies potential patients for program inclusion through rapid recognition of clinical/social determinants that indicate patient eligibility.
• Screens patient records, as assigned, using specific criteria and critical judgment, in order to identify adverse events, sub‑optimal patterns or care and or utilization.
• Facilitates communication and coordination between all members of the care team to coordinate appropriate discharge plans and facilitate placement program.
• Demonstrates ability to work collaboratively with community resources specific to population (age, diagnosis, ethnicity, religion) served. Attend / Coordinate patient and/or family care conferences as needed.
• Maintains daily/accurate statistical data and identification of barriers to managing independent workload.
• Submits statistical reports as required.
• Participates on projects as required for program planning and evaluation.
• Maintains current knowledge of care coordination practice including specific knowledge of the biopsychosocial issues of adult and geriatric populations.
• Attends mandatory and other departmental in‑services.
• Provides coverage as assigned.
• Participates in hospital, departmental and unit meetings.
• Supports and maintains existing standards of the Public Health Trust, the department and the profession.
• As needed attend rounds to discuss high LOS / complex cases and serve as a resource to assist Clinical Resources Management throughout JHS.
• Respects and maintains patient confidentiality.
• Maintains current knowledge of advance directives.
• Assesses documents and forms for completeness.
• Contacts nursing homes and community agencies as needed for placement purposes.
• Maintains current knowledge of the regulations, policies and procedures regarding nursing home (NH), assisted living facility (ALF), independent living facility (ILF) and Shelter placement. Contact patients, families, and…