Care Transition Coordinator 2

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees.  We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Proactively assist the Care Transition Manager with providing information to the patient regarding the transition of care.  Develop relationships to facilitate discharge planning and continuum of care needs. Performs duties to avoid readmissions and ER visits to the hospital.  Analyze and trend data to improve overall utilization metrics.

Job Responsibilities

• Educating the patient about what to expect, review criteria to determine benefit structure,   authorize and approve benefits as medically necessary. 
• Engage the patient and caregivers upon admission to the hospital and throughout the hospital stay, discharge instructions, transition preparedness, follow-up appointments, and care, using teach-back methodology to assure the patient the patient understands the treatment plan and is well prepared for transition to the next level of care; in coordination with the Care Transition Manager.
• Assists the unit nurse and Care Transition Manager with medication reconciliation at admission and near the time of discharge, assuring that medications are those that are likely to be continued as outpatient considering those on the formulary and the affordability.
• Notifies the Primary Care Physician (PCP) of the patient’s admission to the hospital and facilitates a conversation between the hospital treating physician and the primary care doctor. Collaborates with interdisciplinary team to assure that the plan of care is well understood and documented in the medical record. Participates in rounds with physicians, case managers, social workers as needed.  Assures the discharge documents are delivered to the PCP and to care management at Hill Physicians.  Works closely with the onsite Case Manager and the Hill Concurrent Review nurse to assure post discharge services are authorized and planned at the longest time possible before discharge.
• Assures that tests, consultations imaging studies, treatments and procedures are performed in a timely manner and that any barriers that might cause delays are identified.  Contacts doctors or members of the care team when needed to move the patient’s care forward.
• Makes PCP follow-up appointment as soon as possible after admission with primary care doctor (and with specialists as needed) for a visit for not more than 10 days after discharge.  Assures that the appointment time is known by the patient, by the unit nurse, and is recorded on the discharge document; including the arrangement for home health, home infusion, durable medical equipment, skilled nursing and rehabilitation.  The Transition Care Coordinator collaborates with the interdisciplinary team to assist in the implementation of the identified discharge plan.
• Refers patients to Hill Physician Case Management for post-discharge ‘Welcome Home’ program,

In collaboration with the CTM and team:

• Provide resource information and referrals. 
• Interpret and coordinate health plan benefit coverage with member’s healthcare needs. 
• Refer patients to Health Education and Health Plan Disease Management programs as appropriate. 
• Coordinate all services and interventions with all participating providers and member by effective and timely communications. 
• Negotiate for out of benefit/network services and for cost effective healthcare utilization.

In collaboration with the CTM and team:

• Measure outcomes to determine if quality and cost effectiveness of case management is met. 
• Examples of outcomes data include, but are not limited to member surveys, quality of life, clinical, and financial data. 
• Participate in Quality Improvement activities by analyzing quality data, such as member survey results, and recommend opportunities for improvement.
• Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards. 

In collaboration with the CTM and team:

• Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes. 
• Coordinate internal and external resources for the individual member. 
• Utilize existing reports and systems to identify and monitor utilization resource patterns and facilitate needed care coordination in order to support Quality Improvement. 
• Refer to Hill Concurrent Review Supervisor for supportive interventions as needed, i.e., Health Education, Quality Management, etc. 
• Assures that patients whose surgeon desires co-management are seen by consultant or hospitalist. 
• If determined of benefit to the patient, arranges visit by a home-visiting physician into the patient’s home. 
• If requested by ACO leadership or supervisor, extends visits in person into a skilled nursing facility or rehabilitation facility. 
• Attends ACO, Hospital, Health Plan meetings as needed.
• Required to drive or travel daily for work related duties.
• Other duties as assigned

Required Experience

• 3-5 years of related managed care experience required
• As a representative of HPMG at the onsite facilities, must have the ability to coordinate effectively with a variety of customers including members, providers, hospital and office staff, health plans, internal departments, community resources, and peers.
• Ability to work effectively with a variety of customers including physicians, hospital and office staff, and members
• Ability to work independently as well as in a team environment
• Multi-tasking and ability to prioritize, and strong critical thinking skills
• Excellent organizational and communication skills and ability to meet timeframes
• Computer literate: Excel in routine applications software and Internet resources, including Microsoft Word and Excel
• Strong ability to analyze and trend UM data, and develop a process improvement plan
• Experience with CPT/ICD9 codes preferred.

Required Education

• High School Diploma/GED required
• Medical Assistant Certificate preferred

Additional Information

Salary: $30 - $33 hourly

Hill Physicians is an Equal Opportunity Employer