Transitions Care Coordinator (RN) / UM Shore @ Easton

Easton, MD
Mar 13, 2018
Apr 12, 2018
Support Staffing
Contract Type
Full Time
What You Will Do:

UM Shore Regional Medical Center is currently seeking a Transitions Care Coordinator (RN), located at our Eason, MD facility.


Responsible for assessing each readmitted patient and those patients who are at high risk for readmission; identifying readmission causes, providing on-going patient education, establishing and implementing an appropriate transition plan, coordinating the patient’s plan of care, and closely managing the patient’s course of treatment to ensure optimal and efficient utilization of resources. Serves as a liaison to post-hospital care providers and community resources.


  • Concurrently assesses each readmitted patient and those patients identified as being at high-risk for readmission. Identifies cause of readmission and/ or high risk indicators for readmitting. Establishes an appropriate transition plan for each patient addressing needs for follow-up and arranges the plan. Follows up with patient/family via phone call post-discharge when necessary. Refers to Social Work when necessary.
  • Maintains communication with the patient’s healthcare team to effectively and efficiently move patient safely to a lower level of care.
  • In coordination with the healthcare team, makes recommendations for further services or placement in order for the patient to achieve optimal level of functioning. Assures the transition plan is in place and has been coordinated with all necessary providers, including the patient/family.
  • Serves as a liaison to link the patient with the most appropriate community or state resource. Offers and explains options to the patient and family. Maintains current knowledge of available community and state resources and services.
  • Utilizes Meditech and Midas software according to guidelines to document Care Coordination activities.
  • Participates as an active member of the Utilization Management and Transitions in Care Committees.
  • Actively attends meetings, work groups, rounds, etc. as identified by Director and/or at the request of other departments, staff, etc.
  • Provides requested data regarding readmissions as established by the Director and others.
  • Strive to achieve excellence of services as described in the CARE Commitments.
  • Responds to Shore Regional codes as appropriate.
  • Responsible for honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.
  • Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.
  • Performs related duties as assigned.

  • What You Need to Be Successful:
    • Bachelor’s Degree in Nursing
    • RN Licensure in the State of Maryland.
    • Three to Five years of recent experience in an acute care hospital.
    • Credential in Case Management preferred.
    • Demonstrated excellent verbal and written communication, interpersonal and organizational skills required.

    We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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