Transitional Care Coordinator

Job Summary 

The Transitional Care Coordinator plays a key role within the Quality team, contributing to improving care coordination and ensuring timely follow-up after hospital discharge. This position is responsible for coordinating post-discharge appointments, retrieving hospital records, and supporting transition of care processes that impact quality outcomes. The role also supports quality initiatives through basic data collection, tracking, and reporting related to care coordination and follow-up activities. The role ensures patients are scheduled appropriately and necessary information is available for follow-up care. The role collaborates closely with the Quality Manager, Chief Compliance Officer, and other internal stakeholders to support quality initiatives by ensuring effective transitions of care, reducing gaps in follow-up services, and contributing to performance improvement efforts. 

• Experience: Minimum of 2 years in healthcare, practice management, or a related field. 

• Bi-lingual preferred but not required 

• Demonstrated oral and written communication skills.  

• Strong knowledge of healthcare, clinical fundamentals and preventive healthcare standards 

• Computer skills and knowledge of applicable software programs including Excel, Word, and PowerPoint. 

• Ability to work with diverse populations. 

Essential Functions 

• Supports care coordination and transition of care workflows, including post-discharge follow-up and appointment scheduling, as assigned. 

• Assist in the collection, organization, and basic analysis of patient care data related to clinical quality metrics, including UDS, HEDIS, and internal performance indicators. 

• Monitor and help close preventive care gaps by identifying needed services and communicating this information to care team members. 

• Conduct patient outreach, discussing preventive screenings, and documenting patient interactions in the electronic health record (EHR). 

• Support quality improvement activities by participating in team meetings and improvement cycles (e.g., Plan-Do-Study-Act). 

• Upload documents and maintain accurate records in the EHR to ensure data integrity and proper tracking of quality measures. 

• Collaborate with clinical staff to provide reminders about care gaps and assist with patient follow-up efforts. 

• Utilize data tools such as registries and reports to help identify trends, patient needs, or areas for improvement. 

• Communicate effectively with team members and departments regarding quality-related information, initiatives, and processes. 

• Assist with preparation of quality reports and presentations for internal stakeholders. 

• Support internal audits and assist during regulatory or compliance reviews as needed. 

• Identify patients with Limited English Proficiency (LEP) or other communication needs and coordinate appropriate interpretation services. 

• Perform other related duties as assigned, supporting the organization’s commitment to improving patient outcomes and quality of care. 

Physical Requirements 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

While performing job duties, the employee is occasionally required to stand; walk; sit; use hands to handle or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.