Transitional Care Coordinator

DAP Health•Coachella, CA

76d•Onsite

About The Position

At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission. Job Summary The Transitional Care Coordinator (TCC) plays a critical role in ensuring patients experience a smooth transition from hospital, emergency, or residential (skilled nursing) care to ongoing outpatient services. This position supports continuity of care by coordinating follow-up appointments, verifying discharge instructions, and serving as a compassionate liaison between patients, providers, and care teams. To facilitate appropriate outpatient care, the TCC proactively engages with discharging facilities. TCCs must be able to identify Social Determinants of Health (SDOH) and enroll eligible patients into case and/or care management programs as needed.

Requirements

Thorough understanding of SDOH and wraparound service models
Proficiency in EHR systems (OCHIN Epic preferred)
Strong interpersonal and communication skills demonstrated through integrity, honesty, and compassion
Minimum 2 years of experience in care coordination, medical scheduling, or case management

Nice To Haves

Bilingual in English and Spanish preferred
Associate or bachelor's degree in healthcare, social work, or related field is preferred
Familiarity with care/case management programs and medical benefits is preferred

Responsibilities

Maintain patient confidentiality in accordance with HIPAA and all applicable laws and regulations
Coordinate timely post-discharge care for patients transitioning from acute or residential settings to primary or specialty outpatient services
Collaborate with hospitals, discharge planners, and community partners to obtain discharge summaries and care instructions
Connect with patients and/or caregivers within 24-72 hours of discharge to review care plans, answer questions, and schedule follow-up visits
Facilitate patient connection with the appropriate nurse case manager to reinforce follow-up care, medication adherence, and awareness of critical symptoms requiring attention
Intake of patient's SDOH; if eligibility, coordinate enrollment into the Enhanced Care Management (ECM) program to ensure immediate access to support services is initiated
Collaborate with internal departments (e.g., social services, referrals, ECM, Case Management) to ensure holistic support
Monitor patient progress post-transition and escalate concerns to appropriate clinical staff when needed
Embrace and adhere to quality initiatives related to preventing re-hospitalization
Document all transitional care activities accurately in the electronic health record (EHR) and other systems to maintain compliance with organizational protocols
Align functions and monitoring systems with Healthcare Effectiveness Data and Information Set (HEDIS) and Uniform Data System (UDS) measures
Attend care team meetings to support patient transitions and follow-up planning
Perform other duties as assigned