Your Role

The Transition of Care (TOC) Coordinator is a member of our interdisciplinary team (IDT) and is responsible for supporting the development and execution of patient care transition plans as they progress from the acute or post-acute care setting to the home environment. The position will directly contribute to improving patient health outcomes, reducing the total cost of care, and reducing unnecessary care and readmissions to the acute or post-acute setting. This role will establish and build relationships with community hospitals and post-acute care settings including but not limited to discharge planners at hospitals, acute rehabilitation, sub-acute rehabilitation, behavioral health settings, primary care practices, and home health agencies.

Primary Functions Include:

• Develop and maintain strong relationships and partnerships with acute care settings, post-acute care settings, and community-based healthcare organizations.
• Collaborate with discharge planners to ensure transitional discharge plans are in place. Facilitate and schedule post discharge visits with either the patient's primary care provider (PCP) or an Honest Advanced Practice Provider (APP).
• Utilize the health information exchange and other resources (for example, Bamboo Health) to obtain discharge summaries, as needed, and to monitor the movement of patients between settings.
• Communicate with patients and caregivers before and during the discharge phase to ensure coordination of care.
• Collaborate with Honest leadership to ensure an aligned approach to relationship-building with providers and healthcare organizations in the community.
• Regularly engage with high-volume acute and post-acute settings to round, both in person and via telephone.
• Escalate clinical issues and urgent needs to the care team and provide daily updates on the census to primary care providers and care management teams.
• Remain responsible for tracking and trending responsibility areas of the transition of care process.
• Ensure that post-discharge appointments are scheduled and that they occurred.
• Document all patient encounters in the appropriate locations.
• Travel to or between local worksites up to 50% of the time.
• Perform related responsibilities as required.

How You Qualify

You reviewed the Who You Are section of this job posting and immediately felt the need to read on. That makes you a match for our innovative culture. You have experience in a healthcare environment, with demonstrated examples of service excellence. You reviewed the essential qualifications section of this job description and believe that you have what it takes to be successful in the position.

• Associate degree in health care, human services or a related healthcare field or at least two recent years of healthcare experience required
• Licensed Practical or Vocational Nurse experience preferred
• Experience in building relationships, community collaboration, and providing education preferred
• Sales experience helpful, but not required
• Must be able to arrange and consistently travel to various work sites, as well as possess and maintain a valid driver's license in your state of residence and motor vehicle insurance
• Ability to effectively communicate preventive health, health education, and health management philosophies to patients/caregivers and agencies
• Knowledge and understanding of medical terminology, direct contracting, and value-based care
• Strong computer skills: ability to run reports, merge data sets, sort
• Skilled in using computer-based programs: Microsoft Office (Outlook, Word, Excel, PowerPoint) or equivalent, Internet searches, electronic health records, etc.
• Ability to quickly establish a rapport and build trusting relationships with others
• Extremely organized