TOC Care Management Coordinator

Admission & Discharge Management

• Reconcile RHIO and Hamaspik Central alerts daily to identify Emergency Department, Observation, Inpatient, Skilled Nursing Facility (SNF), Behavioral Health, and Rehabilitation admissions and discharges.
• Distribute daily admission and discharge notifications to the Medicare TOC Team and Utilization Management.
• Monitor admissions and discharges throughout the day and communicate significant updates to the TOC team.

Care Coordination

• Contact hospitals, Skilled Nursing Facilities (SNFs), rehabilitation centers, and other facilities to obtain member status updates.
• Monitor anticipated discharge dates and communicate discharge readiness to the assigned TOC RN.
• Notify the TOC RN of changes in member status, barriers to discharge, and important clinical updates requiring intervention.
• Coordinate with facility staff to obtain discharge plans and discharge disposition.
• Schedule timely post-discharge appointments with Primary Care Providers (PCPs).
• Schedule specialty appointments as requested to support continuity of care.
• Coordinate communication between facilities, providers, TOC Nurses, Care Managers, Utilization Management, and other interdisciplinary team members.
• Assist in removing barriers that may delay discharge or impact a successful transition back to the community.
• Support continuity of care by ensuring appropriate follow-up services are coordinated after discharge.

Guiding Care Documentation

• Create, update, and close Service Interruptions (SI) for Emergency Department, Observation, Inpatient, SNF, Behavioral Health, and Rehabilitation stays.
• Complete MAP and DSNP Hospitalization/SNF/Behavioral Health Admission Notification scripts accurately and within required timeframes.
• Verify facility information using NPPES and authorization records.
• Maintain complete, accurate, and timely documentation within Guiding Care.

Provider Notifications

• Prepare and fax Notifications of Admission (NOA), Transfers, and Discharges to Primary Care Providers within required timeframes.
• Upload notifications and fax confirmations into Guiding Care.
• Obtain missing PCP contact information when necessary.
• Ensure discharge summaries and supporting documentation are forwarded to PCPs in accordance with HEDIS Transitions of Care requirements.

Discharge Summary Coordination

• Request and obtain discharge summaries from hospitals and facilities.
• Perform ongoing follow-up until discharge summaries are received.
• Review discharge summaries to ensure required HEDIS Transitions of Care elements are present.
• Coordinate with TOC Nurses and Utilization Management regarding missing or incomplete discharge documentation.
• Ensure discharge documentation is distributed timely to PCPs.

Internal Workflow Coordination

• Generate and assign activities for interruption of services during inpatient admissions.
• Generate notification of change in member status activities to assigned Care Managers.
• Generate resumption of services activities following member discharge.
• Coordinate with Authorization, DME, Home Care, Transportation, Vendor Management, and other internal departments to ensure services are suspended and resumed appropriately.

Quality & Compliance

• Maintain and update the HEDIS Transitions of Care (TRC) tracker accurately and in real time.
• Ensure all TRC components, including Notifications of Admission, Notifications of Discharge, PCP notifications, discharge summaries, and supporting documentation, are entered completely and accurately.
• Monitor TRC compliance timelines to ensure all required activities are completed within established regulatory and organizational timeframes.
• Review the tracker daily for completeness, identify outstanding items, and follow up to resolve missing documentation or overdue tasks.
• Collaborate with TOC Nurses, Care Managers, Utilization Management, and other departments to obtain information needed to maintain an accurate and compliant TRC tracker.
• Support HEDIS, CMS Star Ratings, and internal quality initiatives by ensuring the accuracy, timeliness, and integrity of all TRC data and documentation.
• Identify discrepancies, trends, or potential compliance risks and escalate issues to leadership promptly.
• Participate in quality audits and process improvement initiatives to enhance the accuracy and efficiency of the Transitions of Care program.

Required Skills

• Excellent organizational and time management skills.
• Strong communication and interpersonal skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong attention to detail and documentation accuracy.
• Knowledge of Medicare Advantage, DSNP, and Managed Long-Term Care workflows.
• Experience with RHIO, Guiding Care, Hamaspik Central, and electronic medical records.
• Ability to work collaboratively with interdisciplinary teams, providers, hospitals, and community partners.
• Working knowledge of Excel and Word.

Benefits:

• Medical, dental, and vision insurance
• Generous PTO package
• Multiple floating holidays
• 401 (K) with employer contribution