Panoramic Health aims to improve the transition of care from the acute hospital setting to the outpatient clinic for patients with kidney disease. We will accomplish this through collaboration with physicians, hospital staff, clinic staff, and our VBC team. The Transitional Care Coordinator will serve as the primary contact for these coordination efforts. The Transitional Care Coordinator will be present daily within hospitals to help identify patients, obtain information regarding their hospitalization, and coordinate all necessary post discharge care. Responsibilities include:Proactively identifies and rounds on VBC patients within the hospital.Communicates with physicians in hospital to assist in coordinating plan of care.Serves as the primary liaison between the hospital case management and the VBC team.Tracks patients through the acute care process until discharge and alerts appropriate care team members of the patients’ ongoing location status.Determines any unidentified needs from patients and family while in hospital.Tracks patients through the acute care process until discharge and alerts appropriate care team members of the patients’ ongoing location status.Obtains hospital medical records for VBC team and clinic staff for all hospital admissions in market.Coordinates post discharge care with primary care physician, nephrologists, and other specialists.Attends VBC team meetings as required.Completes documentation in a timely fashion and complies with regulatory and legal standards.Perform other duties and responsibilities as required, assigned, or requested. Qualifications:HS diploma, associate’s, or bachelor’s with healthcare customer experience or medical assistant experience preferred.3-5 years of related experience.Strong attention to detail and organization. Expert computers skills with the ability to navigate and filter multiple software platforms at once. Impeccable interpersonal skills including the ability to communicate with physicians and other licensed disciplines with ease.Ability to write, speak, and communicate clearly.Customer service acumen. MS Office (Teams, Outlook, Excel), phone systems, and fax.Data entry.Sorting, filing, and reconciliation.Ability to read, write, and speak English.