This job description is for a Patient Care Coordinator/Transitional Nurse position. The role involves initiating patient evaluations, assisting with transitions from facilities to home, coordinating care plans, and providing education to patients and the community. Key responsibilities include assessing patients for home care, coordinating treatment plans, communicating with physicians and staff, and ensuring smooth care transitions. An RN or LPN is required and responsibilities involve coordinating patient care between facilities and home.

1. JOB DESCRIPTION
Title Patient Care Coordinator/ Transitional Nurse JC 721
Department Florida Hospital Home Care Services
Supervisor’s Title Administrator of Florida Hospital Home Care Services
Regular Work Hours
FLSA Status (Exempt /
Exempt
Nonexempt)
Date of Last Revision February ,2012
JOB SUMMARY
This position is accountable for initiating an evaluation in the hospital setting or SNF by conducting the
initial an assessment of the patient and family for appropriateness of and acceptance to home health
services. This includes assisting the patient in the transition from the hospital or SNF to home or may
include evaluating the patient in his own home. This position is also responsible for implementing
specific patient care planning activities such as collecting patient clinical and demographic data,
planning of home health care with the attending physician, members of the multidisciplinary team and
arranging for support services. Discharge planning services may be provided at the agency’s hospital
only with a written agreement. This position also provides community awareness programs to educate
residents and referral sources of services offered by home health. This position needs a highly
organized person who can multitask and possess strong communication skills. An RN or LPN is
required for this position.
PRINCIPAL DUTIES and FUNCTIONS
All essential functions must be performed. Reasonable accommodations may be made to
enable individuals with qualified disabilities to perform the essential functions.
• Working with Case Management in hospital / facility setting to help identify appropriate home
care referrals ensuring a smooth transition from facility to patient’s home for continuum of care
• Respond to requests for care from referring sources within the community in a timely manner.
• Obtain information to verify insurance coverage and inform patients.
• Identify primary and /or secondary payer of services.
• Participate in establishing the plan of treatment through direct communications with the patient’s
physician by obtaining specific orders of care.
• Explain the function of the health team members who will implement the plan of treatment to the
patient.
• Coordinate the start of care activities with Intake person & the Patient Care Supervisor.
• Function as an expert resource for interpreting Medicare home health guidelines.
• Communicate pertinent information and instructions for specific physician’s orders to health
team members, including completion of the interdisciplinary referral.
• Provide information to physicians and the community on the benefits and alternatives home
health services can provide.
• Participate in and attend appropriate staff and committee meetings as directed by the
Administrator.
• Document patient care coordinating activities according to department procedures.
• Makes appropriate referrals for patients not accepted for care.
• Conducts patient visits as deemed necessary by the Administrator.
• Assumes responsibility for administrative calls as assigned.
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2. • Enhance personal and professional growth through attendance at workshops, conferences and
individual research and reading and/or participate in professional organizations.
• Adhere to all department policies, procedures, standards of patient care and department
guidelines.
• Participate in the orientation of personnel.
• Complete special related tasks as assigned by the Administrator.
• Other duties as assigned
RESPONSIBILITIES
1. Establishes and maintains courteous, tactful and professional level of interpersonal skills
necessary to deal effectively with:
• Patients
• Guests
• Medical staff
• The public
• Co-workers
• External business associates
Exhibits positive SHARE values in all interpersonal contacts.
2. Demonstrates effective communication skills; is able to report and convey required information
either verbally or in writing; maintains required level of confidentiality; consults with and/or
advises appropriate personnel of situations requiring follow-up or attention.
3. Conforms to all Adventist Health System corporate, Florida Hospital Heartland Division
organizational, and departmental policies and procedures including but not limited to:
• Mission
• Values
• Employee Covenant
• Corporate Compliance
• Rules of Conduct as outlined in the “Guidelines for Employees” handbook
• Smoking
• Dress Code
4. Establishes and maintains a history of regular attendance; makes appropriate use of PDO, and
observes department call-in procedures for absence; establishes and maintains punctual work
habits. Exhibits timely arrival and departure and dependable time habits including meal and
other breaks.
5. Attends/participates in mandatory facility-wide and department training/meetings as required
(including but not limited to: annual education, safety training, etc.). Is able to demonstrate and
apply knowledge of fire, safety, security and disaster procedure regulations as presented in
orientation, outlined in safety manual, and as pertains to each work area.
6. Supports departmental and organizational Mission through:
• Appropriate use of resources
• Providing assistance to team members
• Accepting work or schedule assignments
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3. • Participating in process and performance improvement as required
7. Required to respond to emergency situations (i.e., disasters, hurricanes, etc.) by reporting to
department and staying until the crisis is over or position is covered by incoming personnel.
This is a mandatory requirement. Refusal to respond may result in termination.
8. Contributes to the successful achievement of department-stated goals and objectives and will
facilitate staff cohesiveness and communication.
EQUIPMENT USED:
Computer, printer, calculator, phone, fax.
SUPERVISION RECEIVED and GIVEN:
Supervised by the Administrator
JOB SPECIFICATION
Education/Experience:
• Graduate of an approved school of Licensed Practical Nurse
• At least two (2) years of nursing experience , preferably one (1) year of experience in home
health or public health nursing
• Demonstrate knowledge of community resources and the medical community
• Extensive clinical knowledge and evaluation skills with experience in developing patient care
plans
• Demonstrate understanding of the home health care delivery system and patient eligibility
Certificates, Licenses and Registrations:
• Currently licensed to practice as a Licensed Practical Nurse in the State of Florida
• CPR Certification
• Valid Florida driver’s license (Required)
• Automobile liability insurance (Required)
Age-Specific Competencies
Must be able to demonstrate the knowledge and skills necessary to provide care, based on physical,
psychosocial, educational, safety, and related criteria, appropriate to the age of the patients served in
his/her assigned service area as indicated below. The skills and knowledge needed to provide such
care may be gained through education, training, or experience.
• (0-30 days) Neonate
• (30 days-12 years) Pediatric
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4. • (13-17 years) Adolescent
• (18-65 years) Adult
• (65+ years) Geriatric
Physical Demands
Significant portion of daily assignment involves application of manual skills requiring motor coordination
and finger dexterity.
Light to moderate exertion driving to and from hospitals, nursing homes and ALF’s.
Work positions and body movements required: walking, standing, driving, sitting, bending, stooping,
kneeling, reaching, lifting.
Physical Environment: Varied patient care environment (animals, no air conditioning, smoking, stairs).
Mental and Communication Skills
Able to do the following
Frequently: interpersonal skills, problem solving, reading, typing and writing.
Continuously: computer literacy, talking and telephone.
Occasionally: training/supervising
Vice President APPROVAL: ________ Date:
EMPLOYEE ACKNOWLEDGEMENT: Date:
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