Transitional Care Coordinator

Wellbe Senior Medical•Chicago, IL

About The Position

The Transitional Care Coordinator (TCC) is an office-based, telephonic role responsible for managing the daily hospital census of engaged patients and coordinating care for members who are hospitalized or in post-acute facilities. The TCC schedules post-discharge transition-of-care (TOC) appointments with WellBe practitioners and works with hospital and skilled nursing facility personnel, WellBe transitional care liaisons, patients, and families to support smooth transitions and encourage adherence to follow-up care. The role supports WellBe’s clinical team by tracking admissions and discharges, updating electronic records, retrieving and uploading pertinent medical records, communicating facility updates, and escalating patient concerns or care coordination needs. The TCC also explains WellBe’s program and care model to patients, conducts post-discharge calls, documents health and social needs, and coordinates TOC visits according to protocol.

Requirements

High school graduate or GED.
Strong verbal and written communication skills.
Strong attention to detail and accuracy in data entry, record keeping, and following protocols.
Proficiency with computer applications and electronic documentation; comfort using EMRs and other software platforms.
Excellent customer service skills, with an empathetic and compassionate patient-centered approach.
Ability to communicate effectively with older adults and understand their unique communication needs.
Professionalism, adherence to ethical standards, maintenance of patient confidentiality, and integrity in interactions.
Ability to lift up to 20 pounds; patient moving, lifting, or transferring may involve lifting up to 50 pounds and assisting with weights exceeding 100 pounds.
Ability to stand for extended periods.
Fine motor skills and visual acuity.

Nice To Haves

At least 2 years of experience in an acute care or post-acute care setting.
Experience with case management, discharge planning, referral coordination, or admissions coordination.
Experience as a health unit secretary or health unit coordinator.
Managed care experience.

Responsibilities

Practice the WellBe mission of helping patients lead healthier, meaningful lives by delivering complete care.
Manage the daily hospital census of engaged members and review new alerts.
Update POS, disposition, discharge dates, and other information to keep the EMR accurate; escalate data discrepancies to the data team.
Communicate with hospitals and discharge planners, notify patients of WellBe’s awareness of their hospitalization, and track hospital and facility admissions.
Identify discharge barriers and care coordination needs by reviewing HIE or hospital EMR information and contacting relevant personnel.
Retrieve and upload medical records for emergency department, observation, inpatient, rehabilitation, and skilled nursing facility admissions when electronic retrieval is unavailable to HIM teams.
Explain WellBe’s transitional care visits and comprehensive care model to patients and families and seek consent to schedule post-discharge appointments.
Collaborate with facility personnel and WellBe transitional care liaisons on discharge planning and post-discharge visits.
Make structured, scripted post-discharge calls to engaged members; ask about and document general health status, medications, discharge instructions, social determinants of health, and follow-up scheduling.
Use the EHR to manage and update patient data based on communications from hospital and SNF partners and share relevant information with the WellBe clinical team.
Schedule transition-of-care visits according to protocol after a patient is discharged from a facility.
Verify admissions to skilled nursing facilities, obtain estimated length of stay, and coordinate with SNF and discharge-planning personnel and WellBe transitional care liaisons.
Escalate patient concerns, discharge barriers, and post-discharge needs to the APP or Care Management Director.
Huddle regularly with Transitional Care Liaisons and coordinate on high-priority facilities and patients.
May participate in weekly interdisciplinary team meetings.
Perform other duties as required by the manager to accomplish team objectives and goals.