Mohawk Valley Health System
Utica, NY, USA
Job Summary The RN - Transitional Care Coordinator is responsible for assessing patients that are medically complex and at high risk for readmission to ensure a successful transition from the hospital to community. The Transitional Care Coordinator RN is accountable to reduce the challenges that patients face post discharge and prevent hospital readmissions. Core Job Responsibilities Assess, plan, implement and evaluate the needs of patients for transitional care needs. Track and report variances in standards of care that impact our readmission rates. Coordinate the post-discharge workflow by anticipating potential gaps in care and education needs. Evaluate and follow-up for assigned patients who require medication reconciliation, adherence assessment, management of acute and chronic disease states, assessment of patient’s ability to perform self-care/instructions, coordination of post-discharge appointments and care coordination services. Coordinate...
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Administration & Operations
Nursing
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