Transfer of Care Coordinator
Transfer of Care Coordinator
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$ 22 - 23
1 Vacancy
Job Description
Job Details
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 Transfer of Care Coordinator (TCC) plays a critical role in ensuring continuity of care for patients following hospital emergency department or skilled nursing facility visits. The TCC proactively engages patients post-discharge to facilitate timely follow-up appointments address barriers to care and support transitions back into outpatient settings. In addition the TCC is responsible for screening and enrolling eligible patients into the Enhanced Care Management (ECM) program connecting them to long-term wraparound services.
Supervisory Responsibilities: None
Essential Duties/Responsibilities
- Identify and track patients discharged from acute care settings to ensure timely primary or specialty care follow-up
- Collaborate with hospitals discharge planners and community partners to obtain discharge summaries and care instructions
- Contact patients by phone telehealth or in-person to schedule and confirm post discharge visits
- Educate patients and caregivers on the importance of follow-up medication management and red flag symptoms
- Use Epic and other tools to document all care coordination activities
- Screen patients for eligibility and facilitate enrollment into the Enhanced Care Management (ECM) program
- Coordinate with ECM Referral Coordination Social Services and other internal teams to remove barriers and ensure holistic care
- Track and monitor appointment compliance and escalate concerns to clinical teams as needed
- Support quality initiatives related to hospital readmission prevention and HEDIS metrics
- Attend care team meetings to support patient transitions and follow-up planning
- Maintain HIPAA compliance and proper documentation standards
- Perform other duties as assigned
Qualifications
Required Skills/Abilities
- Knowledge of case management or care coordination practices
- Understanding of social determinants of health and wraparound service models
- Proficiency in EMR systems (Epic preferred)
- Excellent communication follow-through and customer service skills
- Strong organizational skills and ability to manage multiple priorities
- Bilingual in Spanish preferred
Education and Experience
Experience with transitional care and hospital discharge processes preferred
Familiarity with ECM program guidelines and Medi-Cal benefits is a plus
Working Conditions/Physical Requirements
This position is on-site at DAP Health Sunrise
Ability to lift 24 pounds
Operates in an office/clinical setting frequent use of phone and computer systems
Required Experience:
IC
Employment Type
Full-Time
