Transitional Care Coordinator

Job Details

Coachella Valley Community Health Center - Coachella CA

Full Time

$19.80 - $22.00 Hourly

Health Care

Description

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 youre 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 asmooth transition from hospital emergency or residential (skilled nursing) care to ongoingoutpatient services. This position supports continuity of care by coordinating follow-up

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

Determinants of Health (SDOH) and enroll eligible patients into case and / or care managementprograms 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 residentialsettings to primary or specialty outpatient services
• Collaborate with hospitals discharge planners and community partners to obtaindischarge summaries and care instructions
• Connect with patients and / or caregivers within 2472 hours of discharge to review careplans answer questions and schedule follow-up visits
• Facilitate patient connection with the appropriate nurse case manager to reinforcefollow-up care medication adherence and awareness of critical symptoms requiringattention
• Intake of patients SDOH; if eligibility coordinate enrollment into the Enhanced CareManagement (ECM) program to ensure immediate access to support services is initiated
• Collaborate with internal departments (e.g. social services referrals ECM CaseManagement) to ensure holistic support
• Monitor patient progress post-transition and escalate concerns to appropriate clinicalstaff 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 andInformation 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

Required Experience :

IC

Key Skills

Senior Care,Hoyer Lift,Medical office experience,Dementia Care,Home Care,Nursing,Alzheimers Care,Administrative Experience,Meal Preparation,Medication Administration,Memory Care,Tube Feeding

Employment Type : Full-Time

Department / Functional Area : Health Care

Experience : years

Vacancy : 1

Hourly Salary Salary : 19 - 22