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Job Details

Transition Care Coach - RN

Employer Visiting Nurse Service of Rochester
Location Webster, NY
Hours Must work Tuesday - Saturday, 8:30 - 5:00 pm with occasional need to flex days and hours based on need.
Rate / Salary not listed
Posted 07/15/14
Status Full-time


1. RN, MSW, or Other allied health professional
2. Minimum of 1-2 years experience in the home care, health care or community based organization. .
3. Strong communications and organization skills
4. Spanish speaking is a highly desirable
5. Knowledge of medical terminology
6. Ability to be flexible and adjust practice based on patient population being served.
7. Strong education/teaching background
8. Experience in managing complex problems and developing creative solutions.


Acts as facilitator of interdisciplinary collaboration and care continuity across care settings, coaching patients and caregivers to play an active and informed role in care plan execution utilizing the Coleman Model and/or adaptations required by insurer.

1. Participates and assures that the Care Transitions Services are consistent with the pilot design and meets customer needs.

A. Promotes the Care Transitions philosophy and ensures the delivery of quality care.
B. Promotes effective working relationships and works effectively as part of the pilot project to meet the goals and objectives established.
C. Promotes positive, supportive, respectful communications to all external sources, patients, families and staff.

2. Develops and maintains a customer oriented environment responsive to the needs of all external/internal customers.

Direct Coaching Duties:
A. Initial case finding and screening of patients by group. Hospital/ED contact with patient for final screening and completes Hospital Visit intervention for the Care Transitions Program.
B. If patient appropriate for program, contact insurer as required regarding program enrollment and obtain any needed authorizations. Interfaces with VNS intake department for referral generation.
C. Begin interactions regarding patient goal setting and the role of the transition coach.
D. Be sure patient has initial Primary Care Physician (PCP) appointment set before discharge.
E. Arrange for first home visit within 24-72 hours.
F. Initiate the use of the Personal Health Record (PHR), complete assessments as needed
i.e. Patient Activation Measure (PAM) and/or Patient Activation Assessment. Completes documentation in electronic record day of service.
G. Maintains journal of interventions and coaching “stories” for use in program evaluation and program development.
H. Establish visit schedule and continue to act as patient educator – advocate, and patient empowerment facilitator to move patient to improved self management skills and enhanced patient – practitioner communication.
I. Assure coordination and communication between patient and all care providers.
J. Complete follow up telephone calls with patient to check status and document.
K. Maintain open communication with insurer Disease Care Managers.
L. Maintain and provide data as requested to demonstrate project progress.
M. Manage caseload of approximately 30 patients and assure productivity per standards.

How to Apply

Call for an appointment: Professional Recruiter - Visiting Nurse Service of Rochester, (585) 787-2233 Ext. 8242. E-Mail Resume and Cover Letter to Professional Recruiter - Visiting Nurse Service of Rochester, spugsley@vnsnet.com..

Deadline: 7/29/14

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