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Rn - Clinical Transition Specialist
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- Act as a liaison working with patient/family and physician to determine next level of care
- Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients.
- Initiates timely referrals to other health care team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)
- Arrange DME, Home Care, Hospice, assisting with returns to ECFs, and Transportation
- HRHC: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success.
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