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Check with seller Transitions Of Care Coordinator - Health Care for the Homeless, Full Time, Days Boston

Published date: April 3, 2022
  • Location: Boston, Massachusetts, United States

Transitions of Care Coordinator – HCH Liaison supports HCH Clinical team by performing non-clinical aspects of care coordination, transitions and referrals as an integral part of the HCH integrated care team. Incumbent assists homeless patients to navigate systems of care along the healthcare continuum. Incumbent reaches out to meet homeless persons seeking care at local emergency rooms and hospital inpatient units in order to enroll them as patients of HCH clinic system. Incumbent arranges referrals, supports linkages, and facilitates transitions for HCH patients who require specialty care and services, insuring smooth care transitions and successful adherence to healthcare regimens recommended by HCH Clinical team.

PRINCIPAL DUTIES AND RESPONSIBILITES

Transitions of Care Coordinator – HCH Liaison performs under direct supervision of RN Lead Care Coordinator and in conjunction with HCH Nurse Care Coordinators and within established practice policies and procedures, performs the following essential functions:

Transitions of Care Coordinator:
1. Review, prepare, and assemble EMR clinical record for each patient visit to ensure that it is complete and up to date with pertinent documents such as discharge summaries, continuity of care forms, diagnostic results and consultation reports. Time permitting, assist Program Assistants-Front Desk team with intake, registration and scanning processes.

2. Monitor Voice-Mail box for Nurse Coordinators to retrieve and relay clinical messages. Document and follow up on non clinical messages and requests from patients and other parties.

3. Obtain Prior Authorization from Health Insurance Carriers, as indicated, to approve referrals, medications, and diagnostic procedures for each patient discharged; inform Ordering Provider about any declined Prior Authorizations.

4. Arrange and book Referrals to specialty care and community partner providers as ordered; forward proper HCH referral documents to respective referral providers; inform Discharge Nurse about any questions or issues related to referral bookings.

5. For State Immunization Program, assist Nurse Care Coordinators with inventory management, program implementation and adherence to all policies and procedures.

6. Work directly with patients to arrange for Transportation and/or Escort to referral appointments; inform Discharge Nurse about any questions or issues related to patient adherence, transportation services, escort needs and referral sources.

7. Work directly with patients to arrange Medication Assistance Program, local Pharmacy services, and local welfare support to ensure that patients access and receive medications as prescribed; inform Discharge Nurse of questions or issues related to medication access.

8. Work directly with staff, patients and VNA to arrange for durable medical equipment or home care services as prescribed; inform Discharge Nurse of any related questions or issues.

9. As indicated, assist HCH Social work staff with application documents and record transfer requests related to the provision of shelter, housing, entitlements and disability assistance.

10. Coordinate details of HCH clinic visit Discharge Plan, as directed by Discharge Nurse, to ensure access to community resources as ordered by HCH provider and clinical team.

11. Track referrals to specialty care and community partner providers and agencies as well as diagnostic testing to verify success of referral / adherence; document and notify patient’s HCH PCP about referrals and testing not completed. Revisit / re-book care plan with patients as directed.

12. Track appointments to HCH clinic to tally broken appointment rate and identify patients at risk of being lost to follow-up; Initiate patient outreach and care alerts.

13. Arrange, facilitate and track internal team referrals of HCH patients to other HCH providers and members of the team; track and tally no shows / broken appointments to identify those lost to follow-up; notify ordering HCH provider and HCH team member in order to rebook referral.

14. Order Clinic supplies and Stock Exam Rooms as directed by Nurse Coordinators.

15. Participate in HCH Quality Improvement plans, working with staff to create reports that track success rates and compliance with referrals to community partners and with diagnostic testing.

HCH Liaison:
1. Work with ER (emergency room) and inpatient hospital staff, to facilitate referrals, transitions, and communication among entities on behalf of patients who are homeless; track and tally ER visits and inpatient discharges of current homeless patients and new referrals.

2. Remain available to ER and inpatient staff in order to meet homeless persons in need of discharge planning and enrollment into HCH care; perform HCH program Intakes as indicated.

3. Teach emergency room, inpatient hospital staff and community partners about unique needs and access to care barriers faced by homeless persons, and ways in which HCH program can help.

4. Reach out, engage and enroll homeless persons in community; assist them with HCH Intake and Medicaid applications as indicated.

5. Assist patients to navigate through systems of healthcare and community social services, by arranging transportation and providing escort to appointments as indicated.

6. Assist patients to maintain linkages with specialty care, community providers, other health and human service partner agencies, to promote adherence to recommended healthcare plan.

7. Participate in HCH clinical case management and outreach team meetings to share perspectives about outreach and referral coordination related to patient care plans and community agency partnerships.

8. Participate in community partner agency meetings, as directed, to collaborate with other homeless, health and human service agencies to identify service gaps and improve access.

Qualifications

Education:

  • Associates degree in health or business or related field.
  • BS preferred.
Experience:
  • Experience with / appreciation of unique needs of a vulnerable population
  • Ability and willingness to work with vulnerable populations in a non-judgmental manner
  • Ability and willingness to work as a member of a multi-disciplinary team
  • Experience with care management or project coordination
Skills:
  • Strong Communication Skills; interpersonal and written.
  • Teamwork skills
  • Computer Skills
  • Organizational Skills / Ability to Multi-task / Priority Setting Skills
  • Initiative – Self Direction
Licensure/Certification:
  • None
Primary Location: US-NH-Manchester
Job: Service Positions
Schedule: Full-time
Shift: Day
Employee Status: Regular
Job Type: Standard
Job Level: Non Manager

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