Aftercare Coordinator

Essential Functions

• Assesses complex patient aftercare needs, risks, support systems, service eligibility, and potential barriers to successful care transitions.

• Assists in the management of aftercare programs, projects, workflows, caseload priorities, service resources, and performance-improvement activities.

• Develops more complex individualized aftercare plans that address follow-up treatment, medications, appointments, community resources, equipment, education, and support needs.

• Implements processes to coordinate referrals, authorizations, appointments, provider communication, patient outreach, and confirmation of required services.

• Ensures aftercare plans, referrals, interventions, patient communications, outcomes, and unresolved barriers are documented accurately and completed within established timeframes.

• Confers with patients, families, clinical teams, care managers, payers, community providers, and external agencies to coordinate services and resolve transition-of-care concerns.

• Interprets clinical information, treatment recommendations, eligibility requirements, coverage limitations, and available resources to guide aftercare decisions and recommendations.

• Coaches patients, families, and less-experienced team members regarding aftercare expectations, available resources, care-transition practices, and methods for addressing service barriers.

• Helps establish and implement aftercare procedures, educational materials, staff guidance, quality standards, and process improvements.

Level of Supervision Received

Plans and arranges own work; works with manager to prioritize projects.

Education Aftercare Coordinator

Required:

• Bachelor’s of Science in Nursing
• OR Bachelor’s degree in Physical Therapy from a school accredited by the American Physical Therapy Association
• OR Bachelor's degree in Occupational Therapy from an accredited university
• OR Master's degree in Speech - Language Pathology from an accredited university
• OR Master's Degree in Social Work

Work Experience Education can be substituted for experience.

Required:

3 years Direct Patient Care

Preferred:

1 years

Burn unit experience

Knowledge, Skills, & Abilities

Adept at problem solving and decision making skills|Medium|Required

Adept at collaboration and teamwork|Low|Required

Adept at growth mindset (agility and developing yourself and others) skills|Low|Required

Adept at execution and delivery (planning, delivering, and supporting) skills|Low|Required

Adept at digital literacy skills|Medium|Required

Licenses/Certification(s)/Registration(s)

Required/ Preferred:

• Must have current RN license or valid temporary permit with the Texas Board of Nursing or valid Compact RN license

• OR Must be licensed by the Texas State Board of Social Work

• OR Must have current licensure as a Physical Therapist with the Board of Physical Therapy Examiners for Texas

• OR Must be registered as an Occupational Therapist by the State of Texas

• OR Must be licensed by the Texas State Board of Examiners for Speech - Language Pathology and Audiology and have completed all requirements for a Certificate of Clinical Competence (CCC) issued by the American Speech and Hearing Association (ASHA).,

• ABLS within 12 months of hire; BLS within 6 months of hire;

• Completes Phoenix Society SOAR Coordinator Course to facilitate the SOAR Program within 6 months of hire

Level of Responsibility

Leadership & Talent: Typically responsible for providing guidance, coaching and training to other employees within job area.

Communication & Influence: Communicates information within and outside the job area on matters that involve obtaining or providing difficult or sensitive information requiring some explanation and interpretation for patients and others within the care team.

Influences others within own job area and patients regarding policies, practices and procedures.

Organizational Impact; Executes clinical processes to solve difficult and sometimes complex problems to meet patient needs and/or deliver high-quality care to patients.

Knowledge & Experience: Requires clinical license and/or certification typically obtained through education and moderate to advanced practical knowledge of job area obtained through experience.

Typically viewed as a specialist within discipline.

Less than 2 years prior relevant

Problem Solving: Uses judgment based on the analysis of information.

Interpersonal Skills: Developed communication and diplomacy skills used to direct/persuade/influence others.

Project Management: Senior project/program team member responsible for work flow which is varied in nature with situations frequently requiring new solutions.