Overview Job Summary:

Demonstrates through behavior Decatur Morgan Hospital's mission, vision and values. The CTN helps patients move through different levels and types of care before, during and after their hospital stay. The CTN makes sure all physicians therapists and other caregivers have the information necessary to deliver appropriate care to the patient in the appropriate setting. The CTN provides post discharge follow-up evaluations to ensure compliance with discharge instructions Responsibilities Key Responsibilities / Essential Functions 1. The Clinical Transition Coordinator (CTC) is responsible for the effective delivery of care and interdisciplinary collaboration of medically complex and high-risk patient populations under the DMH Hospitalist service. 2. Oversees transitions of patient care and provides effective coordination across the continuum of care within the DMH system as well as with outpatient and post-acute care providers to improve patient outcomes, decrease healthcare costs, and optimize the patient experience. The goal is to assure quality of care as the patient transitions through the medical system. 3. Provides regular assessments of patients, including making home visits in some cases, and works with the patient's medical team to chart the patient's progress and monitor how well it follows the plan. 4. Educates the patient to ensure understanding of medical instructions and that the medical team understands the patient's needs and concerns. 5. As the patient's advocate and the care team's representative the CTC is the liaison to achieve beneficial outcomes for the patient and DMH. 6. Assist in achieving a reduction in readmissions and average length of stay. 7. Has oversight to assure that home health referrals and post discharge plans are appropriate for the patient and executed to prevent any discharge delays. 8. The CTC behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the health care team.

Qualifications Minimum Knowledge, Skills, Experience Required:

Education:

Minimum RN with current license to practice in the state of Alabama Nurse Practitioner preferred.

Experience:

A minimum of 2-3 years experience in the duties of care coordination. Strong clinical evaluation and decision making skills. Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles.