Transition of Care Management Coordinator

Job Description

Job Description

SUMMARY 

As a member of the Transitional Care team, the Transitional Care Coordinator (TCC) will function as the key patient advocate as it relates to the coordination of post-acute care needs and other health system resources. As a clinic-based resource, the TCC collaborates with all clinic departments to ensure the successful transition of the patients from the hospital and back to the PCP to manage their chronic illness. 

The practice of this position has a direct impact on patient outcomes and CNCHC performance measures. The Transitional Care Coordinator utilizes research findings in practice and participates in Transitional Care program design, implementation, and evaluation, and participates in ongoing quality improvement activities. He/she collects clinical path variance data that indicates potential areas for system-wide improvement of cares and services and provides identifying errors and discrepancies in care that negatively impact the patient. The Transitional Care Coordinator then seeks to rectify errors and discrepancies through a broader system approach. This approach includes contacting individual discharging providers, including attending and resident physicians, to provide feedback on gaps in care. 

ESSENTIAL DUTIES AND RESPONSIBILITIES include but are not limited to the following functions: 

A. ASSESSMENT  

• Contact patient and care giver within 48 hours after discharge to schedule an appointment with the Primary Care Provider (PCP) and review and reinforce the discharge care plan.
• Conduct/coordinate/reinforce medication reconciliation, and Transition of Care Management (TCM) document in EHR.
• Post-discharge care coordination – including scheduling and ensuring completion of follow-up visit with the primary care provider or specialist within seven days and referral to case manager and other resources as needed. 
• Follow-up communication/coordination with the patient’s physician within 48 hours of discharge. 
• Educate patient/caregiver about indications that the discharged patient’s condition is worsening and when/how to respond. 
• Train the PCP on how TCM documentation and follow up
• Identify specific data needs as well as information/data sharing workflows to enhance transition care. 
• Collaborate with Health Information Exchange platform such as LANES and Medex, Health plans, IPAs, and hospitals to receive faxed and electronic copies of hospital census data for their patients on a daily basis. 
• Access clinical information and discharge notes/plans and upload it into the EHR. 
• Report utilization data to clinics on an ongoing basis. 
• Document and track the discharge and transitional care activities and resources provided to each patient. 
• Consolidate data and prepare dashboards documenting process activities/outcomes on a monthly basis for review by quality team. 
• Evaluate causes of relevant readmissions (within 30 days) to determine if additional transition supports are needed. 
• Monitor compliance with transition workflows. 
• Ensure that members have 24/7 access to clinical advice and support.

B. LEADERSHIP

• Coordinates and facilitates patient progression throughout the continuum. Collaborates with all members of the healthcare team and external customers. 
• Participates in clinical performance improvement activities to achieve set goals. 
• Applies advanced critical thinking and conflict resolution skills using creative approaches. 

C. EDUCATION

• Participates in the orientation of new department staff. Provides learning opportunities for students in various health care disciplines as requested. 
• Supports agencies as requested through the Department of Quality Management. 

D. EDUCATION  

• Participates in research surrounding transitional care. Identifies recurring clinical practice issues and contributes to the development of specific plans to address identified issues.
• Participates in activities that support the advancement of care transitions, case management, and discharge planning through literature review, professional organizations, research, committee participations, etc. Consistently uses new knowledge, technology, and research in practice. 
• Performs other duties as assigned. 

QUALIFICATIONS 

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

EDUCATION and/or EXPERIENCE 

• Minimum one year of Medical Assistant experience or is proficient in Medical Terminology. 
• One year of appointment scheduler experience. 
• CPR certification. 
• California driver’s license and current auto insurance. 

NECESSARY SKILLS  

• Excellent interpersonal communication, problem-solving, customer service and conflict resolution skills. 
• Excellent organizational skills and attention to detail. 
• Excellent time management skills with a proven ability to meet deadlines. 
• Computer skills in word processing, database management, and spreadsheets. 
• Ability to travel to clinics within Los Angeles, Riverside and San Bernardino Counties.

Monday - Friday 8:00am - 4:30pm