Transition of Care Coordinator

The role

You will manage patients moving from hospital, observation, skilled nursing or emergency care back to primary care. You will do post-discharge outreach, schedule follow-up visits and coordinate home and support services.

What you will do

• Review daily admission, discharge, transfer and emergency department lists from all sources and build one daily worklist
• Identify high-risk patients and escalate them to Case Management and Clinical Leadership
• Contact patients or caregivers within two business days of discharge and document each attempt
• Schedule follow-up with the Primary Care Provider within seven calendar days of discharge
• Confirm appointments, reschedule no-shows and document barriers such as transportation or cost
• Send discharge summaries and facility records to the provider before the follow-up visit
• Coordinate home labs, APRN home visits, home health, equipment and transportation
• Work with skilled nursing, assisted living and hospice facilities as needed
• Keep records in the EMR and care management platform and support quality measure documentation
• Protect patient information under HIPAA and related rules

Required qualifications

• High School diploma, Certificate of Attendance, Certificate of Completion, GED, or equivalent
• Medical Assistant, clinical background, foreign medical practitioner, or equivalent medical experience
• Minimum of two years of experience in a healthcare setting
• Fluent in English and Spanish

Nice to have

• One year of experience in care coordination, case management, discharge planning, or transitions of care
• Experience with Medicare Advantage, Medicaid and Marketplace/ACA populations in value-based care
• Working knowledge of transition-of-care and post-discharge quality measures
• Experience with an electronic medical record and a care management or population health platform

Before you apply

• Bilingual English and Spanish is required

About the company

NeueHealth is a healthcare company that delivers care through its owned clinics Centrum Health and Premier Medical, and through affiliated providers. It also supports providers in performance-based arrangements.