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Transitional Care Specialist

Company: Covenant Healthcare
Location: Saginaw
Posted on: June 1, 2021

Job Description:

Covenant HealthCare






The Transitional Care Specialist (TCS) provides care coordination and care management to patients with chronic conditions/complex illness during the initial 30 days post-discharge, often a period of increased vulnerability. Coordinated planning of a patient's care following a hospital stay can greatly affect health outcomes, likelihood of readmission and/or future emergency room visits, as well as cost to patients, providers and insurers.

The Transitional Care Specialist (TCS) is a Registered Nurse whose general responsibilities are focused on: 1) ensuring continuity of care for patients transitioning from Covenant Medical Center to another environment, and 2) improving the patient's self-management knowledge and skills, primarily in the areas of medication management, condition management and patient confidence about what is required of them during the transition and beyond. The Transitional Care Specialist (TCS) demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Mission, Vision and Values of Covenant and the commitment to Extraordinary Care for Every Generation.


Identifies targeted high risk population at risk for readmission by diagnosis, risk stratification, PCP referral, discretion of case management/hospitalists/Transitionalist NP.

The TCS works with the Transitionalist NP to identify and set priorities and risk specific intervention strategies to reduce the likelihood of readmission.

Reviews records of identified patients, visits patients in-house to conduct a general assessment of preparedness for discharge. Builds rapport with patient while in-house to set expectation for continuity of contact once patient discharged.

Provides patient follow up and coordination of care to identified patients following discharge from hospital including facilitating any additional outpatient work-up required, and monitoring pending test results and taking appropriate action.

For those patients without a primary care provider, TCS will contact a local provider on the patient's behalf to facilitate an appointment.

Telephone outreach to identified patients within 24-72 hours post discharge. The TCS: reviews the AVS/discharge instructions with the patient, checking for understanding; validates medications are available in the home and being taken as prescribed (medication reconciliation); validates resources delivered/rec'd (DME, home care, etc.)

Work with ECC case managers when HM patients present to ECC within the 30 day window since last admission.

Uses motivational interviewing and coaching to empower patient/caregiver; assesses patient; Uses "teach back" communication technique with patients including warning signs/symptoms requiring immediate medical attention; problem solves barriers to compliance.

Works with key community partners (primary care providers, specialists, senior services such as Meals on Wheels, etc., VNA/Home Health, SNF/assisted living facilities, etc.) Where appropriate, identifies and creates opportunities to enhance relationships, communication, transition processes between Covenant inpatient setting and community partners.

Improves information flow between inpatient and outpatient providers

Initiates, completes and maintains required documentation for all activities.

Works with staff and leadership of Hospital Medicine, Quality, Case Management, PHO, and others, to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance effectiveness/quality of transitional care, including standardizing systems of care during patient transitions. Continue to adapt as issues are identified and solutions trialed.

Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice. Also, stays abreast of national readmission strategy successes/failures.

Measures/monitors impact of program. Analyzes data/produces reports to track readmission rates of target population.

Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines (under indirect supervision of HM physician).

Develop, implement and oversee feedback mechanisms to provide current information on the progress of patients back to the PCP.

Establishes and maintains effective working relationships with HM enrolled PCPs/office nurses.

Develop & support initiatives to improve patient satisfaction with HM and Covenant.

Other information:


Current Licensure to practice as a Registered Nurse in the State of Michigan.

Graduate from an accredited institution.

Continuing medical education as required by the certification body.

BLS Certification Required.

Bachelors Degree in Nursing or related area preferred.

Minimum of three years of experience with adult medicine in hospital setting, primary care/ambulatory care, home health agency, or skilled nursing facility within the past five years.

Case Management or Care management experience preferred.

Experience as participant in continuous quality improvement preferred.

Experience in self-management support (Health Coaching) preferred.


Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.

Knowledge of Covenant systems, policies and procedures.

Knowledge of acute and chronic care protocols, administration of medications and treatments, delivery of care and documentation of care.

Knowledge of medical practices, terminology, billing and reimbursement

Knowledge of common safety hazards and precautions to establish a safe work environment.

Demonstrates customer focused interpersonal skills to interact in an effective manner, gaining trust and building rapport with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

Demonstrates ability to take initiative, work autonomously and be directly accountable for practice.

Demonstrates ability to influence and negotiate patient & family caregiver decision-making.

Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, and work organization.

Critical thinking skills and ability to analyze complex data sets.

Excellent assessment and triage skills.

Excellent interpersonal, facilitation, and patient education knowledge, skill and ability.

Computer proficiency. Must be able to work with an EMR system while providing patient care.

Analytical skills necessary to plan, develop, and administer care to a wide variety of patients.

Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.

Ability to manage complex clinical issues utilizing assessment skills and protocols.

Ability to implement evidence base interventions and protocols for chronic conditions.

Respond calmly and effectively in emergencies.

Make decisions within scope of training and practice.


Ability to maintain punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.

Constnat handling, feeling, talking, hearing and near vision.

Frequent lifting up to 25 lbs.

Frequent standing, walking, twisting, reaching, midrange vision, depth perception, color vision and field of vision.

Occasional lifting up to 100 or more lbs.

Occasional sitting, lifting, carrying, pushing, pulling, stooping, kneeling, crouching squatting, tasting, smelling and far vision.


It has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant's premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.

Keywords: Covenant Healthcare, Saginaw , Transitional Care Specialist, Other , Saginaw, Michigan

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