Transitional Care Specialist - RN

Job Title:

Transitional Care Specialist - RN

Location:

Woods Cross, UT 84010

Position Type:
Full Time

Education Level: 2 Year Degree

Salary: $90,000.00 - $98,000.00 per year

Travel:
Road Warrior

Job Shift: Day

Job Category:
Marketing

Business Development

Director of Transitional Care

Serves as a vital clinical bridge across the Rocky Mountain Care continuum, providing education and support to patients, families, and clinicians on identifying hospice-appropriate patients, assessing hospice eligibility, and ensuring compassionate, seamless transitions.

• Active Registered Nurse or Licensed Practical Nurse license in the state of Utah or a valid compact state license.
• Minimum of 3-5 years of Hospice experience with demonstrated success in case management in home health and hospice, or transitional care.
• Knowledge and experience in working with multiple post-acute continuum of care services.
• Strong communication and relationship skills with the ability to market and grow a Hospice census as well as RMC continuum care transitions.

• Participates in an open and collaborative relationship between the administrators, business development team, central intake, Home Health and Hospice teams, business office, and the admissions office working toward shared continuum of care service growth.
• Performs daily duties assigned by the Director of Transitional Care to facilitate the conversion of referrals to admission status and growth in transitions of care to RMC services.
• Communicates with external team members regarding referral status and any additional information needed to assist with Hospice transitions.
• Communicates daily with RMC continuum of care team members to facilitate smooth transitions of care with each RMC service.
• Builds relationships with local hospitals, provider groups, and community members to educate on the RMC continuum to grow census.
• Based on clinical needs, regularly travels throughout RMC areas to support multiple teams and ensure continuity of care across service areas.
• Works in a helpful and pleasant manner, daily using the telephone to communicate with families, residents, patients, hospitals, insurance companies, etc. related to transitioning patients.
• Uses a computer, electronic medical record, spreadsheets, and other tools related to processing referrals.
• Informs the Administrator/Regional Director of Business Development of obstacles or barriers to transitions.
• Maintains daily referral tracking information as assigned by the Administrator/Regional Director of Business Development.
• Communicates with interdisciplinary team members timely regarding assessments and findings of current patients.
• Demonstrates interpersonal relationship skills by developing and maintaining trust with coworkers.
• Completes the daily census for the facility as well as the daily census/status for RMC transitions of care.
• Collaborates with members of the interdisciplinary team, family members, hospitals and community, etc. in a manner that resolves issues and improves the transition process.

• Partner with the Home Health interdisciplinary team (IDT) to maintain a consistent, five-star patient experience.
• Check in consistently with patient and family assuring a continued 5 star experience.
• Assist patients and families in assuring a five-star review.

Facilitate appropriate, timely, seamless transitions to Rocky Mountain Home Health, hospice, and other Continuum services.

• Serve as a key liaison to ensure well-coordinated care across settings and with family support systems.
• Coordinate communication with all units of continuum to ensure smooth and seamless transition.

• Model and promote Rocky Mountain Care’s five-star customer service standards.
• Communicate, educate and support staff in enhancing the patient experience.
• Track patient feedback and lead service recovery efforts as needed with all business units of continuum.
• Communicate systemic or unique transition barriers to the Director of Transitional Care.

• Promotes…