Transition of Care Coordinator

The Transition of Care Coordinator (TOCC) is responsible for managing the patient’s transition from an inpatient, observation, skilled nursing, or emergency department setting back to the primary care setting. The TOCC identifies admitted and discharged patients through health information exchange (HIE) admission/discharge/transfer notifications, health plan census files, state-provided feeds, and facility notifications, and reconciles those sources into a single daily transition-of-care worklist.

Working under the guidance of Clinical Leadership, the TOCC completes post-discharge outreach, schedules and confirms timely follow-up with the Primary Care Provider, ensures the discharge summary and supporting facility records reach the provider before the follow-up visit, and coordinates the home-based and ancillary services the patient needs to remain stable after discharge, including home labs, APRN home visits, home health, durable medical equipment, transportation, and disease management referrals.

The TOCC serves as the liaison between the patient, family or caregiver, facility discharge planners, health plans, and the internal care team, and is accountable for documentation that supports transition-of-care quality measures, readmission reduction, and continuity of care. Other duties may be assigned to suit the demands of the patient population, as this position is committed to the constant pursuit of excellence in improving the health status of the community.

ESSENTIAL JOB FUNCTIONS

Census and Identification

1. Reviews the daily admission, discharge, transfer, and emergency department census from all available sources, including the HIE feed, health plan files, state-provided feeds, and direct facility notification.
2. Reconciles census sources into a single daily transition-of-care worklist and removes duplicate, out-of-network, or non-attributed patients.
3. Identifies high-risk and high-utilization patients in collaboration with the clinical team and escalates them to Case Management and Clinical Leadership.

Post-Discharge Outreach and Follow-Up

1. Completes post-discharge outreach to the patient or caregiver within two (2) business days of discharge notification, documenting each attempt with date, time, and outcome.
2. Schedules the post-discharge follow-up appointment with the Primary Care Provider within seven (7) calendar days of discharge, or within the timeframe required by the applicable health plan or quality measure.
3. Schedules follow-up after an emergency department visit within the required timeframe for the patient’s risk profile and line of business.
4. Confirms appointment attendance, reschedules no-shows, and documents barriers to follow-up such as transportation, cost, language, or caregiver availability.
5. Coordinates completion of medication reconciliation with the clinical team following discharge and documents the date and provider completing the review.

Records and Information Flow

1. Obtains the discharge summary, history and physical, and supporting facility records, and routes them to the Primary Care Provider in advance of the follow-up visit.
2. Documents all transition-of-care activity, outreach attempts, and clinical information in the EMR and care management platform in accordance with organizational documentation standards.
3. Reviews and updates the referral management template and tracks open referrals through to closure.

Care Coordination

1. Coordinates home-based and ancillary services, including home laboratory draws, APRN home visits for disease management, home health, durable medical equipment, and transportation.
2. Coordinates care with skilled nursing facilities, assisted living facilities, and hospice as applicable to the patient’s discharge disposition.
3. Works in collaboration with case managers, hospital records coordinators, providers, home phlebotomists, the clinical team, the Quality/HEDIS department, and center operations to ensure optimal discharge planning and timely follow-up.
4. Serves as liaison between patients, families or caregivers, facilities, health plans, and health care providers.

Quality and Compliance

1. Supports compliance with transition-of-care and post-discharge quality measures and provides the documentation required to evidence measure closure.
2. Maintains patient confidentiality and complies with HIPAA and all applicable federal, state, and health plan requirements governing the use and disclosure of protected health information.
3. Participates in daily huddles, transition-of-care rounds, and team meetings, and responds to routine requests.

General

1. Utilizes critical thinking skills with minimal supervision.
2. Promotes and exemplifies the company mission, vision, and values at all times.
3. Works diligently to ensure optimal work efficiency and meets established productivity and turnaround standards.
4. Conforms to acceptable attendance and punctuality standards as expressed in the Employee Handbook.
5. Performs all other duties as assigned by the supervisor.

QUALIFICATIONS

Required

• High School diploma, Certificate of Attendance, Certificate of Completion, GED, or equivalent.
• Medical Assistant, clinical background, foreign medical practitioner, or equivalent medical experience.
• Minimum of two (2) years of experience in a healthcare setting.
• Bilingual: fluent in English and Spanish.

Preferred

• One (1) year of experience in care coordination, case management, discharge planning, or transitions of care.
• Experience with Medicare Advantage, Medicaid, and Marketplace/ACA populations in a value-based care environment.
• Working knowledge of transition-of-care and post-discharge quality measures.
• Experience working within an electronic medical record and a care management or population health platform.

KNOWLEDGE, SKILLS, AND ABILITIES

1. Strong organizational, time management, and interpersonal skills, with the ability to manage a high-volume daily worklist against defined turnaround times.
2. Patient Centered Customer Service – Whether directly or indirectly, we work to support the delivery of an excellent patient experience to everyone served by the organization.
3. Caring and Compassion – We provide empathic comfort to those in distress and share kindness in all interpersonal interactions.
4. Respectful Communication – We communicate openly, honestly, and without judgment while honoring each individual’s uniqueness and assuming the best of those with whom we interact.
5. Teamwork – We are members of a diverse interdisciplinary team working together to meet a common goal.
6. Accountability – We accept our individual and team responsibilities, and we meet our commitments. We take responsibility for our performance and actions.
7. Customer Safety – We recognize and correct potential hazards to protect ourselves and our customers.
8. Ability to read and interpret documents such as policies and procedures, discharge summaries, benefit information, simple contracts, and procedure manuals.
9. Ability to pay close attention to detail and to ensure the accuracy of reports and data.
10. Proficiency with electronic medical records, telephony systems, and standard office software.