Transitional Care Coordinator

Salinas Valley Health•Salinas, CA

9d•$66 - $91

About The Position

The Transitional Care Coordinator (TCC) ensures smooth transitions of care for patients discharged from the hospital. The role supports population-specific, clinic-specific, insurance-specific, high-risk, and virtual home program patients, with a focus on reducing hospital readmissions, improving outcomes, and enhancing patient satisfaction. In collaboration with physicians, hospital care teams, patients’ families or significant others, and multidisciplinary colleagues, the TCC assesses patient needs and implements individualized plans of care. The TCC coordinates with Transitional Care Program Leadership, the Transitional Care Social Worker, Case Management staff, and other team members to ensure patients have the resources and instructions needed to safely follow their care plans. The coordinator follows up with patients and their support structures to encourage adherence to medical treatment plans.

Requirements

Associate degree in nursing.
Current California Registered Nurse license.
Current BLS/Healthcare Provider status in accordance with American Heart Association standards.
Three years of nursing experience.
Working knowledge of community resources, post-acute care coordination, and case management principles.
Bilingual in Spanish.
Broad general nursing knowledge.
Ability to effectively navigate and use a computerized medical record system.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Case Management experience.

Responsibilities

Meet eligible patients assigned to the Transitional Care Program before discharge, including Virtual Home Program patients in the Emergency Room when needed.
Introduce the program and identify immediate barriers or needs related to outpatient care and support.
Call patients within 24–48 hours after discharge to identify barriers to the discharge plan and facilitate resources as needed.
Call Virtual Home Program patients 12–18 hours after discharge, then complete phone or video calls at least daily and as needed during the specified program timeframe.
Use clinical judgment to triage Virtual Home Program patients, determining whether they need immediate in-person urgent or emergency care, can be managed remotely, or should be directed to another appropriate healthcare provider.
Serve as a resource and educator for patients and their families for at least 30 days after discharge, or for the specified timeframe based on the program or diagnosis.
Intervene on behalf of patients and the organization to reduce avoidable emergency room visits and hospital admissions.
Provide disease-specific education, including medication education, in person, by phone, or virtually as needed.
Monitor patient vital signs; reinforce proper equipment use and vital-sign schedules; record relevant data; alert the healthcare team to critical changes; and track and report laboratory or diagnostic results.
Assess each patient’s condition, diagnoses, medications, and support systems to develop an individualized plan that supports medication self-management, use of a dynamic patient-centered record, appropriate primary and specialist follow-up, and recognition of red flags.
Coach patients in addressing critical issues and self-management tasks rather than taking over and providing care directly.
Document patient and family interactions, assessments, interventions, and care plans accurately in the appropriate electronic healthcare record.
Facilitate follow-up appointments with primary care providers and specialists as needed.
Collaborate with the Transitional Care Program Leadership team and Transitional Care Social Worker when barriers are identified and action is needed.