Transitions Coach (77924)

The Transitions Coach functions as a facilitator of care continuity across care settings, coaching the patient and care giver to play an active and informed role in care plan execution. The Transitions Coach first interacts with the patients in the hospital to ensure a smooth transition home. The Coach's role is to provide practice and support for the patient in identifying concerns and problems and building relationships with practitioners. The coach focuses on skill transfer beginning during the home visit and continuing throughout the 30 day relationship. In this role as patient empowerment facilitator, the Transitions Coach provides practice and guidance to the patient-practitioner communication. Collaborates with colleagues in the Case management Department to insure quality driven, best practice and effective transfers in the movement of patients across the care continuum. Maximizes positive financial outcomes for designated patient populations by intervening at key points in the disease process with home visits, post discharge follow up, phone calls to promote health compliance and prevent readmissions.

Education/Certification:

Current Registered Nurse Licensed in North Carolina, with no restrictions.


Experience:

Previous Experience in Case Management, 5 years or more preferred.