We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Transitional Care Coordinator is responsible for providing administrative support for the transitional care team. This team includes one or more physicians, nurse practitioners, nurse case managers, and social workers dedicated to improving the care of patients transitioning from acute care hospitals to post-acute care facilities and to home. The team’s mission is to improve these transitions in care and prevent the need for repeat hospital admissions. Closely collaborates with the Transitional Care Team members, primary care providers.
Daily responsibilities will include identification and tracking of patients admitted to hospitals and other care facilities, tracking of a high-risk subset of patients after they return to their homes, remote medical record retrieval, review and documentation, post discharge telephone calls, appointment scheduling, planning and tracking of team member activities including hospital and home visits, remote coordination of patient care, and direct communication with primary care providers. This position will also provide opportunities to build relationships with local physicians and leaders in hospitals, post-acute facilities, and primary care clinics. Other key relationships include hospital case managers, hospitalists, physician specialists, skilled nursing and rehabilitation facility staff.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Responsible for transition of care planning and serve as the hub, in collaboration with the case manager, for distribution of treatment plan to community based service providers post discharge.
• Documents all aftercare and transition information in member record.
• Secures discharge and transition plans from discharging facilities and evaluating plans to ensure compliance with clinical and quality requirements.
• Serves as a bridge between inpatient and outpatient treatment providers.
• Notices health plan partner of all inpatient admissions and discharges and engaging health plan staff in discharge planning activities as needed in conjunction with the assigned care manager.
• Works with care management staff to secure required release of information to allow for coordination with and notification to primary care physician and other specialty providers for members transitioning into our out of inpatient levels of care.
• Identifies community resources and services to improve program effectiveness and quality.
• Other duties as assigned and modified at manager’s discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• High Level of proficiency with Microsoft Office Suite, including intermediate Word, Excel & PowerPoint skills.
• Strong interpersonal, communication and critical thinking skills are required.
• Ability to work autonomously is required.
• Fluent in English.

EDUCATION AND EXPERIENCE CRITERIA:

• Bachelor’s degree in related field.
• Two (2) to three (3) years general health care business administration experience in a hospital or post-acute setting.