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Job Summary:

The Patient Transition Coordinator facilitates the transition of care from other levels of the continuum to the Inpatient Rehab Unit. Working closely with acute care coordinators, the IRU Medical Director and the IRU team, the PTC communicates transfer information, eligibility requirements and readiness for admission after collaboration with the Medical Director.

Core Responsibilities and Essential Functions:

Transition of Patients to IRU * a. Communicates with Care Coordinators/referral sources daily to assure adequate information received to make admission decision and to communicate patient transfer plans. * b. Provides information to families/patients on IRU admission * c. Precertifies services with payor source * d. Provides status reports on pending admits to Medical Director and Program Manager Clinical /Regulatory * a. Maintains clinical competence to be able to interpret significance of clinical tests to facilitate decision making * b. Maintains awareness of CMS/PPS requirements regarding medical necessity to facilitate communications in absence of Medical Director * c. Identifies pending diagnostic/lab work from MD consultations that may affect admission/transfer date and notifies all appropriate parties of status * d. Reviews acute care therapy notes to ascertain functional, FIM status to compare to eligibility requirements for admission * e. Monitors daily graphics and test results for pending admissions and communicate to Medical Director * f. Maintains FIM credential needed to assess functional status of patients * g. Adheres to system, hospital, unit policies and procedures, and applicable state and federal regulations Marketing and Referral Development * a. Completes contact/ visits to at least four facilities monthly * b. Develops packet of materials for referral sources to include outcomes, access info and admission process * c. Maintains visibility to internal referral sources by presentation of inservices, twice yearly * d. Develops referral network and provides WellStar overview to at least one new contact per month * e. Defines opportunities to obtain new referrals and develops strategies to achieve Record Keeping * a. Maintains admission/discharge logs * b. Completes pre-admission information (precert, benefits, discharge plans) * c. Creates referral lists for Medical Director with pertinent information * d. Prepares monthly marketing report for review by manager Customer Service * a. Serves as the liaison for the patient/family throughout the admission process * b. Notifies referral source of admission decision status within 24 hours of referral * c. Maintains ongoing communications to all stakeholders on admission and transfer status; participates in service recovery, as indicated; rounds on all pending admits daily * d. Uses AIDET for introductions to customers * e. Maintains professional code of conduct, dress and behavior during the performance of duties Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Diploma from an accredited nursing program Graduate of an accredited nursing program Required or Other Education other related rehab discipline (including- PT, OT, SLP, SW).

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Lic Clinical Social Worker GA or Lic Master Social Worker GA or Master Social Worker or Occupational Therapist or Physical Therapist or Reg Nurse (Single State) or RN - Multi-state Compact or Speech Language Pathologist
• Basic Life Support or BLS - Instructor

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years rehabilitation or medical/surgical experience; Required

Required Minimum Skills:

Excellent written and oral communication skills; excellent time management/organization skills; working knowledge of medical insurance pre-certification process; basic word processing skills; must be able to drive to referral sites for onsite marketing/patient evaluation; extensive walking or mobility required to facilitate internal communications with other members of the care team.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.