Patient Transition Coordinator

Overview

The Patient Transition Coordinator supports seamless care transitions by coordinating referrals to hospice, home health, home infusion, and palliative services. This role works closely with Care Transition Coordinators and Home Health Care Transition Coordinators to ensure patients receive timely and appropriate services. The Coordinator promotes Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation, upholds the Code of Ethical Conduct, and fosters positive working relationships across the organization and with external partners.

• Organizes, tracks, and builds a complete medical record for appropriate patient transition to the home health providers; and confirms start of care (SOC) for each patient referred.
• Responsible for identifying all post-acute care needs and collaborating with the Care Transition Coordinator.
• Collaborates with all Compassus/Ascension at Home intake teams.
• Responsible for completing the transition of care, including submission of complete referral, and securing outside agency placement if Compassus/Ascension at Home is unable to service the patient.
• Organizes and prioritizes large volumes of information.
• Displays exceptional customer service to patients, families, and referral sources.
• Handles confidential and non-routine information.
• Manages and creates general correspondences, memos, charts, tables, graphs, business plans, etc.
• Utilizes computer software applications effectively in word processing, spreadsheets, database, and presentation software (MS Word, Excel, Access, PowerPoint). Requires attention to detail in composing, typing, and proofing materials, establishing priorities, and meeting deadlines.
• Performs other duties as assigned.

• Bachelor’s degree in a health-related field preferred. An equivalent combination of education and experience will be considered.
• Minimum of one (1) year of experience in a related health care setting preferred.
• One (1) year experience in home health, hospice and/or palliative preferred.
• Prior experience with electronic medical records preferred.
• Knowledge of home health, hospice, and palliative eligibility requirements preferred.

• Mathematical
  
  Skills:
  
  Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language
  
  Skills:
  
  Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Other
  
  Skills and Abilities:
  
  Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.

The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 25 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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