RN Care Transition Coordinator – Home Care in Newport News, VA

Newport News, Virginia This role serves as the primary point of contact and face of Riverside At Home, providing exceptional customer service while coordinating patient transitions from acute care, long-term care, assisted living, and community settings, including hospice and GIP services. The position works closely with care management, discharge planners, providers, and palliative care teams to identify and manage referrals, complete clinical reviews, and ensure appropriate service placement. Responsibilities include educating patients and families, verifying information, discussing insurance coverage, maintaining accurate documentation, conducting patient assessments and daily visits, managing symptoms, and collaborating with medical leadership on care plans. The role also requires maintaining up-to-date knowledge of insurance regulations, serving as a resource for At Home services, and participating in staff education to support high-quality, patient-centered care. Overview Performs coordination of services to provide a seamless transition from acute and long term care to Home Care. Elements required for above include data collection and clinical review of all referrals; determination of referral acceptance based on established criteria and collaboration with Home Care team members; attaining and remaining knowledgeable and current related to Medicare/Insurance reimbursement and basic coverage criteria, and of service lines and products; and conferencing with patients, families, DC planners, physicians, medical staff and others to coordinate and facilitate transition and services. Works closely with facility care management/DC planners to identify potential referrals for Home Care Services. Provides exceptional customer service and serves as the 'face' of RHCD to all contacts by telephone, in person and via electronic media. Provides leadership to and supervision for the RHCD Patient Transition Coordinators. What You Will Do • Performs coordination of services to provide a seamless transition from acute and long-term care to Home Care. Completes clinical review of data collected and accurately determines appropriateness and acceptance of referrals based on established criteria. Coordinates services and dissemination of information, and facilitates transfer of referral to other agency for referrals declined by RHCD. Performs any follow up and continues communication with all parties until referral is complete and/or services are provided or canceled. • Serves as an information resource for all RHCD services including contact information, coverage criteria, availability of services and alternatives to RHCD services when appropriate. Provides exceptional customer service by tone of voice, willingness to help, using clinical knowledge to collect complete and appropriate data for referrals, and to field phone calls/pages/in-person inquiries efficiently and appropriately. • Accurately and efficiently enters data into and retrieves data from various computer systems. Accurately and efficiently records data to specified RHCD forms. • Works closely with care management team/discharge planners to identify potential referrals for RHCD services. • Builds comprehensive knowledge base, and continuously works toward remaining knowledgeable and current of Medicare/Insurance information and regulations, RHCD products and services and community resources. Assists Central Intake Manager with review, updating and creation of policies, procedures and processes as needed. • Performs patient interviews and or family conferences to inform of ordered services, verify demographics, answer any questions, discuss insurance coverage as appropriate, discuss any special circumstances or barriers to a safe transition or care at home as appropriate. Qualifications Education • Program Graduate, Nursing (Required) • Associates Degree, Sociology/Social Work/Nursing (Required) • Bachelors Degree, Sociology/Social Work/Nursing (Preferred) Experience • 1 year Nursing experience (Required) • Home health experience (Preferred) • Case management and health care delivery experience (Preferred) Licenses and Certifications • Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required) • CPR/BLS Certification - American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) within 30 Days(Required) • Clinical Social Worker (Preferred) To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.