Transitional Care Coordinator

Wellbe Senior Medical•, WV

1d•Remote

About The Position

This office based, telephonic position is primarily responsible for managing the daily hospital census of engaged patients and coordinating the care of engaged members who are currently hospitalized or in other post-acute facilities and scheduling post discharge transition of care (TOC) appointments with their WellBe practitioners. The TCC promotes and develops relationships with key personnel in hospitals and Skilled Nursing facilities (SNF’s). This candidate will work collaboratively with those key personnel including WellBe TCLs (transitional care liaisons) to arrange and schedule transition of care visits post discharge and help illustrate to patients the importance of TOC adherence post discharge. The position will help educate patients about WellBe's program, close gaps in communication between patients and care management and nursing staff and coordinate smooth transitions post-discharge. The TCC will also be key support for the WellBe clinical team in coordination of care, providing updates from hospital or facility personnel and uploading pertinent discharge summaries for WellBe clinical team to review prior to TOC appointments.

Requirements

High school graduate or GED
Minimum 2 years of experience in acute care or post-acute care setting preferred
Strong attention to detail.
Candidates should have a meticulous approach to their work, ensuring accuracy and precision in tasks such as data entry, record keeping, and following established protocols.
Proficient in Computer applications and electronic documentation
Comfortable using EMRs and other software platforms allows for efficient and accurate documentation of patient information, treatment plans, and medical histories.
Excellent customer centric focus/service skills
The candidate should possess exceptional customer service skills with a focus on the patient experience. They should be empathetic, compassionate, and able to effectively communicate with patients and their families.
Elevated level of professionalism
Adhering to ethical standards, maintaining patient confidentiality, and demonstrating integrity in their interactions with colleagues, patients, and their families.
Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs.
Ability to stand for extended periods.
Fine motor skills/Visual acuity

Nice To Haves

Preferred experience working with case management, discharge planning, referral coordinator, or admissions coordinator.
Health unit secretary or Health unit coordinator may also apply.
Managed Care experience helpful

Responsibilities

Practices the WellBe mission.
Manage daily hospital census of engaged members.
Review all new alerts and update POS, Dispo, discharge date, ensuring EMR has the most correct/updated information.
Escalate examples/concerns of data discrepancies to the data team for continuous improvement efforts.
Communicate with hospital/discharge planners, notify the patient of WellBe's awareness of their hospitalization, and continuously track hospital/facility admissions.
Identify barriers to discharge and care coordination needs by verifying information through HIE/hospital EMR and direct contact.
Retrieve and upload medical records for all admission types (ED, OBS, IP, Inpatient rehabs or SNFs) as support for HIM teams unable to retrieve records electronically.
Engages in telephonic conversations with engaged patients and their families, providing a thorough explanation of the WellBe program transitional care visits and comprehensive care model, aiming to obtain their consent to schedule a post discharge TOC appt.
Communicates with key facility personnel to collaborate in discharge planning of post facility discharge TOC visits for patients with their WellBe care team.
Structured and scripted phone call attempts post facility discharge to engaged members. Inquire and document patient’s response to general health status, medications, discharge instructions, SDOH (Social Determinants of Health) screening, and scheduling of next visits.
Uses EHR system to manage patient data, makes updates based on communication from hospital and SNF partners, and communicates relevant information to WellBe clinical care team.
Schedules Transition of Care visits (TOCs) per protocol once pt discharged from facility.
Admission verification to SNF, obtain estimated LOS, and working collaboratively with SNF/discharge planners and WellBe TCL’s who may enter those SNF’s.
Escalate patient concerns, including barriers to discharge or post-discharge needs, to the APP (Advanced Practice Provider) or CMD (Care Management Director).
Regularly huddle with Transitional Care Liaisons (TCL) and coordinate on high-priority facilities and patients.
May participates in weekly Interdisciplinary Team (IDT) meetings.
Other duties as required by the manager to accomplish team’s objectives/goals.