Transitional Care Coordinator

Wellbe Senior Medical•Chicago, IL

1d•Onsite

About The Position

The Transitional Care Coordinator 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 coordinator schedules post-discharge Transition of Care (TOC) appointments with WellBe practitioners and builds relationships with hospital and Skilled Nursing Facility (SNF) personnel, working with them and WellBe Transitional Care Liaisons to support discharge planning and continuity of care. The role educates patients and families about WellBe’s program and transitional care visits, supports communication between patients and care management and nursing staff, tracks admissions and discharges, and helps coordinate smooth transitions. The coordinator also supports the clinical team by sharing updates from facilities and retrieving and uploading relevant medical records and discharge summaries for review before TOC appointments.

Requirements

High school graduate or GED.
Strong verbal and written communication ability.
Strong attention to detail and accuracy in data entry, record keeping, and following established protocols.
Proficiency with computer applications and electronic documentation.
Comfort using EMRs and other software platforms.
Excellent customer service skills with a patient-centered focus; ability to communicate empathetically and compassionately with patients and families.
Elevated professionalism, including adherence to ethical standards, patient confidentiality, and integrity.
Ability to communicate effectively with older adults and understand their unique communication needs.
Ability to lift up to 20 pounds; patient moving, lifting, or transferring may involve lifting up to 50 pounds and assisting with weights over 100 pounds.
Ability to stand for extended periods and perform tasks requiring 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.
Review new alerts and update the patient’s POS, disposition, and discharge date to ensure EMR information is accurate and current.
Escalate data discrepancies and concerns to the data team for continuous improvement.
Communicate with hospital and discharge-planning personnel, notify patients of WellBe’s awareness of their hospitalization, and track hospital and facility admissions.
Identify discharge barriers and care-coordination needs by verifying information through HIE or hospital EMR systems and direct contact.
Retrieve and upload medical records for emergency department, observation, inpatient, rehabilitation, and SNF admissions when HIM teams cannot retrieve records electronically.
Communicate with engaged patients and families by phone, explain WellBe’s transitional care visits and comprehensive care model, and seek consent to schedule post-discharge appointments.
Collaborate with facility personnel on discharge planning and post-discharge TOC visits with the WellBe care team.
Make structured, scripted post-discharge calls to engaged members; ask about and document general health status, medications, discharge instructions, SDOH screening, and next-visit scheduling.
Use the EHR to manage patient data, update records based on hospital and SNF partner communications, and relay relevant information to the WellBe clinical care team.
Schedule TOC visits according to protocol after a patient is discharged from a facility.
Verify SNF admissions, obtain estimated length of stay, and collaborate with SNF and discharge-planning personnel and WellBe TCLs.
Escalate patient concerns, discharge barriers, and post-discharge needs to an APP or CMD.
Huddle regularly with Transitional Care Liaisons and coordinate on high-priority facilities and patients.
Participate in weekly Interdisciplinary Team meetings as needed.
Perform other duties required by the manager to accomplish team objectives and goals.