Transition of Care Coordinator

TOTAL CARE CONNECT•Columbus, OH

1d•$70,000 - $75,000

About The Position

The Transition of Care Coordinator (Clinical) is responsible for reviewing daily hospital discharge notifications (ADT feeds), triaging member needs, and coordinating timely post-discharge in-home or telehealth visits. This role serves as the clinical support layer for TCC’s Engagement and Care Coordination teams and plays a critical part in ensuring a safe transition for members returning home after hospitalization.

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.