Transitional Care Coordinator

Everything we do is underscored by a why — and that why is one another.

Location:

Altru Business Center
2401 Demers Ave
Grand Forks, ND 58201

Summary:

The Transitional Care Coordinator (TCC) reviews patients being discharged home with high risk for readmission and identifies needs for home-based services. Collaborates with patient care navigators, health coaches, social work, and other clinicians to facilitate appropriate referrals for post-acute care. The TCC also champions the home-based remote patient monitoring program by facilitating implementation, educating patients and providers, and monitoring readings and outcomes.

Essential Job Functions:

• Reviews patients with high risk for re-admission and coordinates need for home-based services.
• Collaborates with navigators, social work, and payers to facilitate discharge planning needs. Collaborates with community resource persons, primary care providers and multidisciplinary team to deliver services that promote quality outcomes and continuity of care.
• Implements, evaluates, and maintains the remote patient monitoring program, including patient and clinician education and skills validation, policy and procedure review development, review and updating, proper care of equipment and serving as a resource to patients and end users.
• Completes all required documentation within required timeframes.
• Participates in quality assurance and performance improvement
• Performs home health visits as needed
• Other Duties as assigned or needed to meet the needs of the department/organization.

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources
• Registered Nurse | Minnesota Board of Nursing | Within 12 Months of Start Date | HR Primary Sources
• Social Worker | North Dakota Board of Social Work Examiners | Prior to Start | HR Primary Sources
• Social Worker | Minnesota Board of Social Work | Prior to Start | HR Primary Sources
• Basic Life Support (BLS) | American Heart Association (AHA) | Within 90 Days of Start Date | Learning Management System
• Driver's License with Acceptable Driving Record | Driver's License - Current State Licensed | Prior to Start Date | HR Primary Sources

• May be licensed as a RN or Social Worker

Language Requirements:

This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Physical Demands :

• Sit: Frequently (34-66%)

• Stand: Frequently (34-66%)

• Walk: Frequently (34-66%)

• Stoop/Bend: Occasionally (5-33%)

• Reach: Frequently (34-66%)

• Crawl: Rarely (1-4%)

• Squat/Crouch/Kneel: Occasionally (5-33%)

• Twist: Occasionally (5-33%)

• Handle/Finger/Feel: Continuously %)

• See: Continuously %)

• Hear: Continuously %)

Weight Demands:

• Lift -Floor to Waist Level: Sedentary (