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Baystate Health Transitional Care Coordinator in Springfield, Massachusetts


The Transitional Care Coordinator is responsible for the management and oversight of all home health referrals as a key contributor to providing seamless access to care across the healthcare continuum. Responsible for building effective relationships with stakeholders from multiple entities to improve care coordination and promote ongoing collaboration and awareness of the home health service lines. Focuses on patient-centered care planning and serves as an advocate while engaging patients and families with education about home health services and related expectations. Demonstrates competence and knowledge of Medicare COPs and other program requirements. The Transitional Care Coordinator promotes operational excellence and an overall positive patient and customer experience. Consistently demonstrates BHH operating principles of Communication, Integrity, Respect, Trust and Collaboration. Utilizes and promotes use of excellent customer services skills.

Job Responsibilities:

1) Collaborates with case management and/or facility team to ensure safe and optimal transition of care to home health. Attends various hospital rounds, care plan meetings, discharge planning meetings and other family discussions. Provides on site assessment of complex chronic care patients for post-acute care needs to determine goals of care and readiness for discharge to home health services. Reduces barriers to home health admissions utlitizing organization and community resources as appropriate; Responsible for management of referral process to ensure accuracy and a smooth transition to home health. Provides key insight and information that facilitates timely initiation of services in collaboration with the intake specialist and clinical team. Assesses for level of priority for admission to BHH service and triages in collaboration with the clinical team. Documents all clinical coordination notes and follows-up with referral source as needed.

2) Develops positive working relationships with referral sources and provides superior customer service through effective communication and timely resolution of referral issues. Acts as an advocate, liasion and information resource for referral sources as well as patients and their families. Initiates first contact with patients and families to establish home health care and provides overview of services to be rendered.

3) Flexes schedule to meet patients and their caregivers to discuss and plan for services at home. Responds promptly to referral concerns, identifying issues and managing service recovery.     

4) This role is performed onsite at facilities, within the central office or telephonically as directed by the manager of referral services. This role also participates in a weekend and holiday rotation to provide on-site hospital coverage.

5) Educates referral sources on home health standards, home health practices, financial and regulatory requirements. Prepares and delivers presentations to referral sources and other community stakeholders to provide an awareness about BHH's programs and services. Coordinates in-service education for referral sources and care managers.

6) Assembles data and provides analysis and feedback in the form of formal reports and scorecards to key referral sources and stakeholders when necessary.

7) Participates in ACO initiatives to support and promote appropriate post-acute service utilization

8) Provides managerial backup to Transitional Care Manager and/or Manager of Referral Services when necessary

9) Coordination of Business development/marketing/healthcare events, fairs etc.

10) Demonstrates knowledge base of regulations and internal policies and procedures for BHH programs. Attends department meetings and serves on committees and projects as requested. Assumes additional responsibilites as requested. .

Required Work Experience:

1) None Listed

Preferred Work Experience:

1) None Listed

Skills and Competencies:

1) Must possess and demonstrate excellent verbal and written communications skills

2) Must be able to work independently to plan and carry out visits to referral sources, prepare and perform stand-up presentations, and carry out all required follow-up to successfully nurture the referral relationship

3) Professional dress required

4) Strong knowledge of home health care; strong clinical skills; strong knowledge of BHH services and organization

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Associates of Science (Required), Bachelor of Science


Driver License - Other, Registered Nurse - State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.