Description Job Schedule: Full Time Standard Hours: 40 Job Shift: Shift 1 Shift Details: Every day, almost 30,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network as a Transitional Care Coordinator. Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient. As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client’s home. Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients’ families. Basic Purpose of the Position: Work in collaboration with hospital case managers and or social workers, skilled nursing facilities, Assisted living facilities, Independent Living Facilities, home care agencies, and physicians to provide education to customers, patients and families in coordinating the care of patients moving from one level of care to another to ensure a safe and effective patient’s transition across the post-acute care continuum. Serves as a bridge between the healthcare team and the patient and/or caregivers, as well as helps to reduce facility re-admissions. Provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team. Responsible for building and expanding HHCAH relationships as well as identifying opportunities for HHCAH to be a strategic partner generating qualified referrals and building new clinical initiatives. With a goal of achieving excellence in every patient and customer experience, the Central Intake Coordinator’s core purpose is to review referral documentation to clinically assess and align the appropriate level of care, services and programs with the goals of care for the patient based on the information received from the referral source, field Transitional Care Coordinator and/or patient. The CIC will ensure completeness of the referral record, follow-up and collect missing referral documents required for HH regulatory compliance, communicate and coordinate care with Case Management and field TCCs, obtain verbal orders when missing from initial referral documents, monitor fax queue for documents received after initial referral is processed, maintain ownership of all agency referrals after initial processing, process and follow-up on transfer patients and manage patient PING database for HH admissions. The CIC will : • Become educated on levels of care and service across the healthcare system, care navigating as required in facilitating timely coordination of certified or hospice care and services for patients moving from one level of care to another to ensure safe and effective patient transition across the pot-acute continuum. Serves as a bridge between the SSO, healthcare team and the patient and/or caregivers. • Communicate and coordinate referrals and patient care with the onsite TCCs and/or clinical areas to provide seamless care to patients. Acts as agency’s point of contact and liaison for other agency departments. • Locate patients that transfer to hospital and communicate with clinical teams and TCCs. • Receive and resolve inquiries for referral data/items required for coding and billing. • Effective communication skills, self-directed, with a spirit of team support and success, curiosity and ownership, flexibility and a consistent demonstration of H3W Leadership Behaviors and modeling • Efficiency and accuracy in completing work as assigned. • Adherence to regulatory and agency policies and procedures. • This position is within our Homecare Customer Service Department. It is a clinical position with no face to face contact with patients and referral sources. • Accountable for team performance in achieving desired clinical and operational performance measures. • Identifies and facilitates professional development needs and competency for staff. Key Areas of Responsibility: Collaborate and communicate with Primary Care Providers and home care staff to ensure continuity of medical care, to include obtaining, clarifying, validating service requests and completing verbal orders. Communicate with transitional care staff, clinical colleagues, physician’s offices, and home care staff to coordinate homecare orders, follow up appointments, risk factors, insurance parameters and goals of care. Ensure collection and appropriateness of referral documents to support sound medical practice. Reviews demographic and clinical pre-admission documentation, ensuring accuracy of information. Reviews referring and transfer documents and medication list for accuracy and adherence to regulatory compliance and assuring the transitional care processes are implemented. Consistently communicates with HHCAH management to make sure all issues and problems are seamlessly handles so that both the patient and the referral sources are satisfied with the results and process. Assist Homecare Customer Coordinators with F2F requirements and MD verification, when work volumes are high Adheres to the practice of confidentiality (HIPAA and other state/federal regulations) regarding patients, families, staff and the Agency In addition, the position involves other duties such as: 1. Actively participates in the performance improvement process known as H3W. 2. Performs other duties as assigned. Qualifications Minimum Requirements: RN or LPN with an active license to practice in the state of CT. Preferred Requirements: Bachelors degree preferred Experience: Minimum of three years nursing experience in clinical specialty area. Experience preferred: Minimum two years in homecare Language Skills: Strong written and verbal communication skills. Knowledge, Skills and Ability Requirements: • Ability to effectively communicate at all levels within the organization and share knowledge, ideas and information. • Demonstrated success in project management planning and leadership ability. • Able to understand problem situations, solve problems and independently assess a wide variety of tasks in order to effectively take action to identify solutions to benefit the business initiative. • Knowledge of relevant industry standards and proper process application to project or new business/service venture. • Ability to balance financial, quality, people and customer expectation appropriate to business situation. • Intermediate to advanced MS Outlook, Word, Excel and PowerPoint, and Microsoft Project. With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.