Transitional Care Coordinator

At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission.

Job Summary

The Transitional Care Coordinator (TCC) plays a critical role in ensuring patients experience a smooth transition from hospital, emergency, or residential (skilled nursing) care to ongoing outpatient services. This position supports continuity of care by coordinating follow-up

appointments, verifying discharge instructions, and serving as a compassionate liaison between patients, providers, and care teams. To facilitate appropriate outpatient care, the TCC proactively engages with discharging facilities. TCCs must be able to identify Social

Determinants of Health (SDOH) and enroll eligible patients into case and / or care management programs as needed.

Supervisory Responsibilities : None

Essential Duties / Responsibilities

• Maintain patient confidentiality in accordance with HIPAA and all applicable laws and regulations
• Coordinate timely post-discharge care for patients transitioning from acute or residential settings to primary or specialty outpatient services
• Collaborate with hospitals, discharge planners, and community partners to obtain discharge summaries and care instructions
• Connect with patients and / or caregivers within 24-72 hours of discharge to review care plans, answer questions, and schedule follow-up visits
• Facilitate patient connection with the appropriate nurse case manager to reinforce follow-up care, medication adherence, and awareness of critical symptoms requiring attention
• Intake of patient's SDOH; if eligibility, coordinate enrollment into the Enhanced Care Management (ECM) program to ensure immediate access to support services is initiated
• Collaborate with internal departments (e.g., social services, referrals, ECM, Case Management) to ensure holistic support
• Monitor patient progress post-transition and escalate concerns to appropriate clinical staff when needed
• Embrace and adhere to quality initiatives related to preventing re-hospitalization
• Document all transitional care activities accurately in the electronic health record (EHR) and other systems to maintain compliance with organizational protocols
• Align functions and monitoring systems with Healthcare Effectiveness Data and Information Set (HEDIS) and Uniform Data System (UDS) measures
• Attend care team meetings to support patient transitions and follow-up planning
• Perform other duties as assigned

Qualifications

Required Skills / Abilities

Education and Experience

Working Conditions / Physical Requirements