Care Transitions Coordinator Rn/Lpn Liaison

Amedisys Home Health Services Hackensack , NJ 07601

Posted 3 months ago

What You Will Do:

The Care Transitions Coordinator is a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for home health or hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the home setting; and (2) developing the referral relationships of the agency within the community, in accordance with Amedisys policies and procedures.

  • After a patient has selected Amedisys as his or her health care provider, the Care Transitions Coordinator visits the patient onsite to review the physician order, assess the patient's clinical needs and gather clinical information. The Care Transitions Coordinator uses a Point of Service computer application to collect referred patient data onsite and transmit it to the agency. The Care Transitions Coordinator also facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to home.

  • The Care Transitions Coordinator is also responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health plan of care.

  • Face to Face documentation must also be noted in Point of Service computer and communicated to appropriate care center.

  • The Care Transitions Coordinator is also responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.

  • The Care Transitions Coordinator has a strong focus to help reduce ACH 30 day -hospitalizations.


  • Must meet one of the following qualifications:

  • Bachelor's degree with one (1 ) year experience in sales.

  • One (1 ) year successful sales experience within the healthcare industry.

  • Current, unencumbered Registered Nurse license in the state of service. LPN, PT, OT, SLP and PA are considered in some cases.

  • Proven track record of developing and maintaining relationships within a competitive marketplace.

  • Demonstrated organizational skills within a complex, fast-paced environment.

  • Ability to handle stressful situations/deadlines.

  • Excellent oral/written communication, critical thinking, and interpersonal skills.

  • Familiarity with general use and functions of the computer, such as, user names and password concepts; internet; e-mail; navigation of computer desktop, including starting programs, using files, and windows, effectively use navigation buttons and tool bars; ability to self-manage online HR services and online training programs.

  • Ability to communicate effectively with all members of the health care delivery team.

  • Ability to support the philosophy, objectives and goals of the hospice region.

  • Ability to forecast needs, set priorities, and execute against developed strategies.


  • Registered Nurse

  • Experience in home health business development

  • Bachelor's degree in business, management, nursing, or healthcare

See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Transitions Care Pharmacist

Hackensack University Medical Center

Posted 1 week ago

VIEW JOBS 11/7/2018 12:00:00 AM 2019-02-05T00:00 Overview The Transitions of Care Pharmacist is responsible for involvement in the clinical aspects of pharmaceutical patient care including interaction with physicians, nurses, and other healthcare providers. The Pharmacist will optimize medication therapy management to improve clinical, economic and humanistic outcomes. Responsibilities A day in the life of a Transitions Care Pharmacist at Hackensack Meridian Health includes: * Conducts Comprehensive Medication Reviews, and Targeted Interventions to assess appropriateness of all medications including dose and drug regimen to optimize medication therapy and improve clinical outcomes.Engages in active patient-centered medication therapy management through transitional care including medication reconciliation services and discharge assistance: patient counseling on appropriate medical therapy, medication history, admissions and discharge medication reconciliations, facilitation of patient care, coordination of benefits, authorizations and formulary management. * Assist with managing medication costs through coordination of benefits, assistance with prior authorization, formulary adherence, pill splitting, avoiding unnecessary and/or duplicate medication therapies and optimization of the medication regimen. * Consults with the prescriber, the interdisciplinary care team, the patient and/or caregiver to identify/develop patient specific disease state therapy goals. * Provides interdisciplinary support and collaboration; communicates and documents clinical recommendations/interventions to prescribers and the interdisciplinary care team. * Provides and follows up on recommended interventions with prescribers, interdisciplinary care team, other pharmacists, patients and/or caregivers, including appropriate documentation of recommendations and interventions. * Coordinates medication reconciliation across the continuum of care and monitoring to improve clinical outcomes and to help prevent unnecessary readmissions, lapses in care and adverse drug reactions. * Attends interdisciplinary rounds to assist with medication-related plans for day of discharge. * Identify additional therapies needed or therapies no longer needed. * Assists with staffing as deemed necessary by the Director of Pharmacy. * Lifts a minimum of 10 lbs., pushes and pulls a minimum of 40 lbs. and stands a minimum of 4 hours a day. * Identifies the needs of the patient population served and modifies and delivers care that is specific to those needs (i.e., age, culture, language, hearing and/or visually impaired, etc.) This process includes communicating with the patient, parent and/or primary caregiver(s) at their level (developmental/age, educational, literacy, etc.). * Adheres to the standards identified in the Medical Center's Organizational Competencies. Qualifications * BS in Pharmacy or PharmD from a college accredited by ACPE or graduate of a foreign college of pharmacy is required * Two years of work experience. * Strong clinical therapeutic skills and demonstration of knowledge of appropriate medication dosing in geriatric and adult populations. * Must be self-directed and possess excellent organizational skills. * Pharmacy Residency (PGY-1) preferred Performance of the 5 Core Elements of Medication Therapy Management Services:Comprehensive Medication Therapy Review (CMR)Personal Medication Record (PMR)Medication-Related Action PlanInterventions and Referrals Documentation of Services and Follow-Up * Communicates effectively, and possesses strong verbal and written skills. Ability to articulate information in a clear and concise manner and to relate peers, prescribers, interdisciplinary care team, patients and/or caregiver.Demonstrates excellent listening skills, and maintains empathy with callers in tone, language, questions and counseling. Ability to probe and question patients and providers to extract information to understand concerns and needs.Demonstrates professional conduct in dealing with healthcare providers, patients and/or caregivers at all times. Hackensack University Medical Center Hackensack NJ

Care Transitions Coordinator Rn/Lpn Liaison

Amedisys Home Health Services