Responsibilities Full-time | Care Transition Coordinator Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273-bed acute care facility providing quality healthcare to the residents of Aiken and surrounding communities. Aiken Regional Medical Centers has been ranked a top hospital in South Carolina by the Carolina Center for Medical Excellence for its treatment of heart attack, heart failure and pneumonia. Services provided at the hospital include emergency medical care, orthopedic surgeries, maternity, and behavioral health services. Visit us online at: https://www.aikenregional.com The Transition of Care (TOC) Coordinator is a registered nurse who functions as a liaison between the plan, the patient, and the multidisciplinary healthcare team to assist in developing an optimal plan of care for transitioning Medicare patients, primarily those being discharged from hospital inpatient or emergency department services. The TOC Coordinator assesses the needs and coordinates resources within and outside the benefit plan as approved by the DCM to promote optimal health benefits and outcomes (both clinical and financial). Actively participate in daily rounds with nursing and medical staff, determine high readmission possibility and follow through with patients, primary care physicians, insurers, and any other services required to ensure a safe discharge. Address/resolve system issues impeding diagnostic or treatment progress with assigned population; proactively identifies and resolves delays and obstacles to coordinated care. Monitor the patient’s progress, intervening as appropriate to ensure the plan of care and services provided are patient focused, high quality, and cost effective. Provide education as needed to staff, physicians, and patients for transitional care planning needs. Ensure/maintain plan consensus from patient/family, healthcare team, and payer as treatment plan and transitional plan changes. Seek consultation from appropriate disciplines for ongoing care planning. Refer cases and issues to appropriate personnel, i.e. Medical Director, Director of Case Management in compliance with department procedures and follows up as indicated. Follow up with the patient according to established clinical program protocols and time frames to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the plan of care based on the ongoing needs of the patient. Initiate and facilitate referrals to transitional services, which may include but are not limited to home health care, hospice, SNF, LTAC, medical equipment and supplies. Document relevant care transition planning information in the medical record according to department standards. Oversee the partnership with Signify and maintain 100% compliance with documentation, follow through with plan of care, attendance of meetings, and addressing issues as needed. Benefit Highlights Unlimited referral bonuses Tuition Assistance Challenging and rewarding work environment Diverse programming to expand your experience Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans 401(K) with company match and discounted stock plan Pet Insurance Healthstream online learning catalogue with plenty of free CEU courses SoFi Student Loan Refinancing Program Career development opportunities across UHS and its 300+ Subsidiaries! If you would like to learn more about the Care Transition Coordinator position before applying, please contact Danielle Plowden, Recruiter at Danielle.Plowden@uhsinc.com or by phone at 803-641-5642. Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $11.6 billion in 2020. In 2021, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; in 2020, ranked #281 on the Fortune 500; and listed #330 in Forbes ranking of U.S.’ Largest Public Companies. Headquartered in King of Prussia, PA, UHS has 89,000 employees and through its subsidiaries operates 26 acute care hospitals, 334 behavioral health facilities, 39 outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 38 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. One of the nation’s largest and most respected hospital companies, Universal Health Services, Inc. (UHS)* has built an impressive record of achievement and performance. Steadily growing from a startup to an esteemed Fortune 500 corporation, UHS today has annual revenue nearing $10 billion. In 2017, UHS was recognized as one of the World’s Most Admired Companies by Fortune; ranked #276 on the Fortune 500, and listed #275 in Forbes inaugural ranking of America’s Top 500 Public Companies. Our operating philosophy is as effective today as it was 40 years ago: Build or acquire high quality hospitals in rapidly growing markets, invest in the people and equipment needed to allow each facility to thrive, and become the leading healthcare provider in each community we serve. Headquartered in King of Prussia, PA, UHS has more than 81,000 employees and through its subsidiaries operates more than 320 acute care hospitals, behavioral health facilities and ambulatory centers in the United States, Puerto Rico, the U.S. Virgin Islands and the United Kingdom. Mission Statement: To provide superior quality healthcare services that: PATIENTS recommend to family and friends, PHYSICIANS prefer for their patients, PURCHASERS select for their clients, EMPLOYEES are proud of, and INVESTORS seek for long-term returns. Qualifications Graduation from an accredited nursing program License by state of SC, or compact state Minimum of 2 years Utilization Review/ Case Management experience preferred. Recent working knowledge of Interqual criteria and Milliman Care Guidelines preferred. Minimum of 3 years in clinical med-surg nursing practice within a hospital setting. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.