Transition of Care Coordinator RN/LCSW

Job Summary Coordinates transition of care services for TRICARE beneficiaries. The Transition of Care Coordinator provides clinical oversight and coordination for beneficiaries moving between levels of care, supports discharge planning, conducts post-discharge follow up, completes assessments and reassessments as needed, identifies barriers to care, and reviews and processes authorization and referral requests according to policy. Transition of Care Coordinators are responsible for reviewing and remaining knowledgeable regarding the scope of practice of their state of licensure. Transition of Care Coordinators report to the Supervisor, Care Coordination. Profile Coordinates transition of care services for TRICARE beneficiaries. The Transition of Care Coordinator provides clinical oversight and coordination for beneficiaries moving between levels of care, supports discharge planning, conducts post-discharge follow up, completes assessments and reassessments as needed, identifies barriers to care, and reviews and processes authorization and referral requests according to policy. Transition of Care Coordinators are responsible for reviewing and remaining knowledgeable regarding the scope of practice of their state of licensure. Transition of Care Coordinators report to the Supervisor, Care Coordination. Education & Experience Required: Registered Nurse (RN), Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW), with current unrestricted license in appropriate state or territory of the United States Current multistate compact license U.S. Citizenship Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation 2+ years' experience in Care Coordination, Case Management, or equivalent Proficiency in medical data entry, written skills and Microsoft Office Exceptional oral communication skills, strong organizational skills and easily adapts to change Preferred: 3 years' clinical experience 2+ years' Managed Care experience Bachelor's degree or higher in health-related field Case Manager Certification by a certification body (CCMC, ANCC, etc.) Experience in the TRICARE benefit program or the Military Health System Key Responsibilities Utilizes clinical judgment to identify care coordination needs and facilitate care during any type of transition of care. Completes assessments and reassessments for beneficiaries identified as high risk for readmission, evaluating physical, behavioral health, psychosocial, environmental, and support system factors. Coordinates in-home assessments through contracted vendors when elected by the beneficiary and reviews vendor findings to determine next steps. Evaluates discharge instructions, medication changes, durable medical equipment needs, and barriers to adherence or recovery. Identifies gaps in care, unmet needs, social determinants of health, and risks for readmission or adverse outcomes. Performs post-discharge outreach to confirm follow-up appointments, medication access, understanding of discharge instructions, and continuity of care needs. Ensures required Transition of Care (TOC) activities are completed within contractual and operational timeframes. Ensures authorizations are in place to meet clinical care needs and processes referral requests according to policy. Communicates with community providers, TRICARE beneficiaries, Military Treatment Facilities (MTF), caregivers, community resources, and interdisciplinary teams to coordinate care. Escalates complex clinical, behavioral health, safety, or psychosocial concerns requiring higher level intervention or urgent follow up. Prepares and presents cases involving high profile or sensitive issues to the Medical Director for review. Serves as a clinical escalation resource and subject matter expert for non-clinical staff, LVNs, and outreach specialists, providing guidance on clinical appropriateness and beneficiary safety. Reviews and triages referrals, assessments, and outreach findings to determine appropriate next steps and level of intervention. Accurately and completely documents assessments, outreach, interventions, and coordination activities in the Medical Management System (MMS). Refer cases to other TRICARE programs as indicated. Applies knowledge of HIPAA privacy and security regulations to ensure compliance in daily practice. Identifies and reports potential quality or fraudulent cases to Clinical Quality and/or Program Integrity. Participates in Quality Improvement Projects, interdisciplinary case discussions, escalation reviews, and audits as indicated in project documents. Supports training, mentoring, and ongoing education of staff related to transition of care processes and escalation protocols. Maintains compliance with contractual requirements, desk procedures, accreditation standards, and organizational policies. Perform other duties as assigned. Regular and reliable attendance is required. Competencies Commitment to Task: Ability to conform to established policies and procedures; exhibit high personal motivation. Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Teams, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose, and a mature problem-solving approach is required. Ability to accept change and maintain a positive team atmosphere. Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, with empathy and compassion for another's position. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues. Technical Skills: Thorough knowledge of internal policies and procedures, utilization management principles, managed care concepts, medical terminology, and medical management system, clinical decision support tools, International Classification of Diseases, and Current Procedural Terminology. Ability to meet or exceed production standards in compliance with contract. Working Conditions Availability to work any shift Works within a standard office environment, or work from home Extensive phone and computer work with prolonged sitting Department of Defense security clearance required Company Overview Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996. DoD Statement Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Benefits We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes: Medical, Dental and Vision Coverage Paid time off 401(k) Retirement Savings Plan (with matching) Short-term and long-term disability, basic life, and accidental death and dismemberment insurance Tuition reimbursement Paid volunteer time TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $76,000 - $89,000 per year. Equal Employment Opportunity TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws. #J-18808-Ljbffr TriWest Healthcare Alliance Corp.