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Date Posted: 12/07/2020
Location: York, PA 17404
Company: SpiriTrust Lutheran
Job Type: Full Time

SpiriTrust Lutheran is now hiring a FT Care Transition Coordinator

For the third consecutive year, we have been certified as a Great Place to Work! 2020-2021

SpiriTrust Lutheran®delivers an array of programs and services that touch thousands of lives each day. Our name, SpiriTrust Lutheran®captures the essence of who we are and the care and compassion our amazing team delivers. It embraces our Lutheran heritage, our spirit of service, and the reality that people come to us because of their trust in us. 

At SpiriTrust Lutheran®, our employees are a highly valued resource. Their dedication, skill and commitment enable us to provide excellent service and care within our continuing care retirement communities, community outreach programs and home care services. We offer: Competitive salaries Comprehensive benefits package Education assistance Career advancement/professional growth Friendly, team-oriented environment If you are ready to join us for a rewarding career

Basic Qualifications


Education/Training: Current unencumbered RN license for the Commonwealth of Pennsylvania; Bachelor’s Degree in nursing, healthcare administration, public health policy, or related clinical health field preferred.



Skill(s):  Proficient reading, writing, and grammatical skills; proficient in interpersonal relations and communicative skills; ability to work independently and to establish and maintain effective working relationships; knowledge of currently acceptable nursing practice; proficient working knowledge of epidemiology, infectious disease and acute care setting equipment use/knowledge; experience with data entry; PC skills;  general knowledge of insurance carriers or willingness to be trained; possesses broad knowledge of skilled care community services generally available; valid driver's license and dependable means of transportation; visual and auditory skills.


Experience:   A minimum of one (1) year experience in acute care; three (3) years in long-term care normally required.


General Responsibilities


Responsible for serving as the SpiriTrust Lutheran Senior Living Skilled Care Centers representative and resource person for the purposes of managing, receiving, collecting, evaluating and processing acute care referral information, and facilitating the referral of potential and existing residents for needed services; managing and coordinating referrals within the community, as well as with other internal departments; complying with operating policies and procedures and regulatory requirements; communicating with appropriate team members; responding to inquiries or referrals; maintaining appropriate records and providing assigned reports. Supports the maintenance of communities skilled care budgeted census.



Essential Duties


Supports the mission and values of SpiriTrust Lutheran which is: SpiriTrust Lutheran, witnessing to the Gospel of Jesus Christ, provides exceptional health, human, and senior living services by supporting persons in achieving an optimal quality of life.


Interacts with residents, clients, team members, and the general public in ways that demonstrate the agency’s commitment to courtesy, service, and hospitality befitting a church related organization. Exemplifies Senior Living’s Culture of Considerate Behavior.


Maintains current knowledge of standards of practice, and federal, state, and local regulations affecting skilled, personal care, and assisted living levels of care.


In conjunction with program leaders, is kept abreast of current resident acuity, care needs, infection control adherence and bed availability.


Serves as the SpiriTrust Lutheran representative and resource person for  managing the acute care referral/admission intake process including receiving, collecting, evaluating and processing referral information for potential residents in accordance with federal, state and local regulations purpose of which the following are illustrative:



Supports community leadership in maintaining budgeted census and payer mix.


Receives and processes all referrals from a variety of acute care sources and means to include but not be limited to:


In-person interviews


Handwritten or mechanically produced documents


Telecommunication devices


Internet based communications


Assesses client needs by listening and asking appropriate questions to understand individual referrals needs as well as appropriate bed availability for each community.


Obtains necessary admission intake information for referrals.


Evaluates referrals in accordance with agency policies, procedures and resources for approval for admission.


Obtains verification of prospective residents' financial and medical status.  Knows and understands the provisions of payer contracts.


Acts as advocate for each referral to ensure appropriate direction of care.


Maintains accurate records of beds available, daily census information, and other necessary information as required.


Complies with HIPAA regulations regarding gathering, processing, and transfers client information between agency centers as needed.


Participates in the transfer of confidential referral information and agency documents between centers.


Participates in on-call to assure admission services on weekends and holidays.


Acts as liaison between referral sources and centers for the purpose of facilitating and streamlining referral process.


Provides excellent customer service to develop and promote good working relationships with referral sources with the goal of increasing referrals.


Abides by the current laws and organizational standards and procedures designed and implemented to promote an environment which is free of sexual harassment and other forms of illegal discriminatory behavior in the work place.


Identifies, prevents, and reports actual or suspected abuse, neglect, exploitation, and improper use of chemical and physical restraints, in accordance with standards.


Cooperates with, participates in, and supports the adherence to all agency standards, procedures, and practices in support of risk management and overall safety and soundness and compliance with all regulatory requirements, i.e., HIPAA, OSHA, etc.


Abides by and supports the organization’s standard of conduct and culture of considerate behavior by exhibiting behavior that is set forth in the standard of conduct and Senior Livings Culture of Considerate Behavior.  Performs duties in accordance with the standard of conduct and completes annual compliance training.


Reports pertinent information to the immediate supervisor as requested, or according to an established schedule; compiles information as necessary or as directed and provides data to appropriate team members.


Responds to inquiries within given timeframes and within established standards.


Completes educational requirements as mandated by state and federal agencies and to maintain competencies.