Inpatient Transition Of Care Coordinator

Summary

The Inpatient Transition of Care Coordinator is responsible for assisting our members with the transition from the Acute/ SNF setting to home by ensuring they are connected with their PCP for their post discharge appointment. The coordinator also ensures the Primary Care Physician is aware of the change in level of Care for their members and that they receive medical records accordingly so that they can provide adequate care in the outpatient setting.

Duties and Responsibilities

· Retrieves daily admissions and ensures they are being sent to the PCP/Clinic across ALL IPA’s

· Retrieves daily Discharges and ensure that they are being sent to PCPs across all IPA’s

o Includes discharge date and discharge disposition on report

· Prioritizing SNP & CMC members and endorsing those patients to Case Management

· Sorts the discharges and arranges post discharge follow up appointment

o Contact the member to notify them of the appointment date and time.

o Documents all efforts and notes in EZCap under Universal note “TOC COORDINATION”

o Documents TOC Outcome if patient was not scheduled for follow up appointment

o Document “TOC PACKET” after TOC packet has been sent to PCP

o Document “SEEN” with date patient was seen Post discharge

· Prioritizing SNP & CMC members and endorsing those patients to Case Management

· If access issue to PCP is identified (Member is unable to obtain an appointment at their PCP within 7 days of discharge) – Refer member to Post discharge Clinic

· Replying to email requests from Nurses, DC Planners and Case Management

· Communicating and working with other subdepartments, Clinics/PCPs and other Teammates.

· Ensuring feedback is return timely from PCP/Clinic and providing feedback to Lead & Supervisor

· Sending emails to Eligibility to confirm if member is active with IPA, Clinics, & PCPs

· Emailing Fields Reps if clinics are not answering or refusing to provide appointments

· Attending Daily Meetings/Rounds

· Covering for TMs when they are out and assisting TMs when needed

· Participates in special projects as required

Minimum Job Requirements

• High school graduate required, Associates degree or higher preferred.
• Knowledge of Healthcare and Managed Care required.

Skill and Abilities

· Typing 45 word per minutes with accuracy.

· Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point).

· Ability to deal with responsibility with confidential matters.

· Ability to work in a multi-task, high stress environment.

· Ability to meet deadlines

· Bilingual