Transition of Care Coordinator—WVP Health Authority

About the Job


The Transition of Care Coordinator (TCC) and its multidisciplinary team of health care leaders are committed to improving the quality of transitions of care. TCCs will be primarily responsible for working with members, families, facilities, and a multitude of other organizations involved in the members care to ensure safe and comprehensive transitions of care. The TCC will plan, direct and organize member transitions, facilitation strategies to improve services, reach established goals and maintain satisfactory goals.
This is a full-time position Monday through Friday, with frequent travel to hospitals, clinics, skilled nursing facilities or other sites that may facilitate a member’s successful transition. Occasional weekend work as needed.
Primary Responsibilities:
(This list may not include all the duties assigned.)

Evaluate need for and assist with:
• Scheduling follow-up appointments and transportation.
• Prior Authorizations – DME/DMS, medications, Home Health, Parenteral/Enteral services, etc.
• Communicates referral requests to appropriate providers on behalf of the member/representative.
• Arranging/directing member/representative to appropriate community resources
• Identifying potential areas of social determinants to relay to appropriate health care leaders/ICM team
• Guide member/representative in the Transition planning process.
• Engage member/representative in the Transition process
• Acts as an advocate for member’s care by identifying and addressing gaps in transition of care needs.
• Information/communication transfer with multidisciplinary team of health care leaders committed to improving the quality of transitions of care
• Supports and develops employee selection process, work assignments, performance evaluations, and staff development for these services.
• Health Risk Screening Questionnaire completion when indicated
• Helps members with questions and concerns regarding care, providers or delivery system.
• Performs other duties as assigned
Professional Requirements:
Maintains clinical credentials and competencies to be able to work clinically
Maintain patient confidentiality at all times
Report to work on time and as scheduled
Maintain regulatory requirements, including all state, federal and local regulations
Represent the organization in a positive and professional manner at all times
Comply with all organizational policies and standards regarding ethical business practices
Communicate the mission, ethics and goals of the organization
Participate in performance improvement and continuous quality improvement activities
Attends committee, CQI and management meetings as appropriate
Ensures compliance with policies and procedures regarding department operations
Effectively and consistently communicates administrative directives to personnel and encourages interactive departmental meetings and discussions
 Associates degree or higher
 Minimum of five years health care experience
 Anatomy and Physiology
 Above average understanding of multiple disease processes
 Experience with medical utilization
 Medical Terminology
 Basic knowledge of pharmacology
 Working knowledge of health systems
 Comfortable reading and navigating clinical documentation
 Knowledge of community resources that serve a wide range of populations
 Ability to work proficiently in multiple computer systems, i.e. Word, Excel, EHR/EMR, etc.

Knowledge, Skills, and Abilities
 Strong organizational and interpersonal skills
 Ability to determine appropriate course of action in more complex situations
 Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
 Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
 Ability to maintain confidentiality of all medical, financial, and legal information
 Ability to complete work assignments accurately and in a timely manner
 Ability to communicate effectively, both orally and in writing
 Ability to handle difficult situations involving patients, physicians, or others in a professional manner
 Physically demanding, high-stress environment

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