Transitional Care Coordinator
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Job Location:
Coachella, CA - USA
Hourly Salary:
$ 19 - 22
Posted on:
8 hours ago
Vacancies:
1 Vacancy
Department:
Job Summary
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 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 andregulations
- 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
- Thorough understanding of SDOH and wraparound service models
- Proficiency in EHR systems (OCHIN Epic preferred)
- Strong interpersonal and communication skills demonstrated through integrity honestyand compassion
- Bilingual in English and Spanish preferred
Education and Experience
- Minimum 2 years of experience in care coordination medical scheduling or casemanagement
- Associate or bachelors degree in healthcare social work or related field is preferred
- Familiarity with care/case management programs and medical benefits is preferred
Working Conditions/Physical Requirements
- This position is based on-site at DAP Health Clinic assigned
- Requires the ability to lift up to 24 pounds
- Involves regular activity within an office or clinical environment including periods ofsitting standing repetitive motion and frequent verbal communication via phone or in-person interaction
- Infrequent travel is essential for off-site training meetings and supporting otherlocations
- Employees in this role do not provide or assist with emergency medical care or first aid
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
