Clinical Care Coordinator
About The Position
Total Care Connect (TCC) is a mobile integrated health organization delivering in-home clinical and preventive care to members across Ohio and surrounding regions. We support health plans, health systems, and value-based organizations by reaching members where they are — in their homes and communities — to improve access, close care gaps, and reduce avoidable utilization. As a tech-enabled, field-based care delivery organization, our teams provide a range of services including preventive care, chronic condition support, transition-of-care visits, member engagement, and navigation. We operate with a focus on high-quality member experience, operational excellence, and coordinated care across clinical, administrative, and remote teams.
Requirements
- Licensed Practical Nurse (LPN)
Nice To Haves
- Experience reviewing ADT feeds or discharge summaries.
- Familiarity with Medicaid and DSNP populations.
- Experience in home-based care, case management, community paramedicine, or value-based care.
- Strong communication and documentation skills.
Responsibilities
- Review daily ADT/discharge alerts to identify eligible members.
- Assess discharge diagnoses, risk level, and clinical appropriateness for TCC services.
- Prioritize outreach based on clinical needs and post-acute risk factors.
- Determine the appropriate intervention pathway.
- Conduct initial outreach to recently discharged members.
- Confirm discharge details, evaluate immediate needs, and assess potential barriers to care.
- Coordinate with the Care Coordination team to ensure visits are scheduled within required timeframes (24–72 hours).
- Support members with education, planning, and navigation during early post-discharge periods.
- Serve as a clinical liaison to health plan case managers, hospital teams, and discharge planners.
- Provide status updates and close-loop communication back to referral partners.
- Ensure accurate documentation in TCC’s care platform and maintain program compliance.
- Assist in building and improving TOC workflows, SOPs, and process standards.
- Monitor TOC metrics including engagement rates, timeliness of visits, and readmission risk indicators.
- Collaborate across internal teams to improve operational effectiveness.
Benefits
- Health insurance
- dental insurance
- vision insurance
- paid time off
- 401(k)/retirement
- disability
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
