Transition of Care Management Coordinator
About The Position
As a member of the Transitional Care team, the Transitional Care Coordinator (TCC) serves as a patient advocate, coordinating post-acute care needs and health system resources. This clinic-based role collaborates with clinic departments to support patients’ transition from the hospital back to their primary care provider (PCP) for chronic illness management. The position affects patient outcomes and CNCHC performance measures. The TCC applies research findings and participates in the design, implementation, and evaluation of the Transitional Care program, as well as ongoing quality improvement. The coordinator collects clinical path variance data to identify system-wide opportunities to improve care and services, identifies errors or discrepancies that may negatively affect patients, and works to address them through a broader system approach, including providing feedback to discharging providers. The role also coordinates follow-up care, medication reconciliation, patient and caregiver education, clinical information sharing, and documentation. It monitors transition workflows, evaluates relevant readmissions, reports utilization data, and prepares monthly dashboards for quality review. The position collaborates with healthcare teams and external partners, contributes to staff and student education, and participates in research and activities that advance care transitions, case management, and discharge planning.
Requirements
- Minimum one year of Medical Assistant experience or proficiency in medical terminology.
- One year of appointment scheduler experience.
- CPR certification.
- California driver’s license and current auto insurance.
- Excellent interpersonal communication, problem-solving, customer service, and conflict resolution skills.
- Excellent organizational skills and attention to detail.
- Excellent time management skills and a proven ability to meet deadlines.
- Computer skills in word processing, database management, and spreadsheets.
- Ability to travel to clinics within Los Angeles, Riverside, and San Bernardino Counties.
Responsibilities
- Contact patients and caregivers within 48 hours after discharge to schedule a PCP appointment and review and reinforce the discharge care plan.
- Conduct, coordinate, or reinforce medication reconciliation and document Transition of Care Management (TCM) in the EHR.
- Coordinate post-discharge care, including scheduling and ensuring completion of a PCP or specialist follow-up visit within seven days, and referring patients to case managers or other resources as needed.
- Communicate and coordinate with the patient’s physician within 48 hours of discharge.
- Educate patients and caregivers about signs that a condition is worsening and when and how to respond.
- Train PCPs on TCM documentation and follow-up.
- Identify data needs and information-sharing workflows to enhance transitional care.
- Collaborate with health information exchange platforms such as LANES and Medex, health plans, IPAs, and hospitals to receive daily hospital census data for their patients.
- Access clinical information and discharge notes or plans and upload them into the EHR.
- Report utilization data to clinics on an ongoing basis.
- Document and track discharge and transitional care activities and resources provided to each patient.
- Consolidate data and prepare monthly dashboards documenting process activities and outcomes for quality team review.
- Evaluate causes of relevant readmissions within 30 days to determine whether additional transition supports are needed.
- Monitor compliance with transition workflows.
- Ensure members have 24/7 access to clinical advice and support.
- Coordinate and facilitate patient progression throughout the continuum in collaboration with healthcare team members and external customers.
- Participate in clinical performance improvement activities to achieve established goals.
- Apply critical thinking and conflict resolution skills using creative approaches.
- Participate in orientation of new department staff and provide learning opportunities for students in healthcare disciplines as requested.
- Support agencies as requested through the Department of Quality Management.
- Participate in transitional care research, identify recurring clinical practice issues, and contribute to plans addressing those issues.
- Support the advancement of care transitions, case management, and discharge planning through literature review, professional organizations, research, and committee participation.
- Apply new knowledge, technology, and research in practice.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
