Transitional Care Coordinator
Posted on: May 3, 2021
The Transitional Care Coordinator (TCC) plays an integral role
in patient journeys towards better well-being by serving as the
communication link between the patient and their interdisciplinary
health care team. The Transitional Care Coordinator is responsible
for identifying the appropriate post-acute care (PAC) setting and
evaluating a defined population for transitional needs
post-discharge to improve outcomes. This ensures that efficient,
smooth, and prompt health care services will be delivered to the
patient across the continuum of care, beyond a single episode of
care and addresses the ongoing needs of the patient. The TCC
engages the hospital care team, the physicians, post-acute care
providers in the home or home-like setting, the patient and their
families/caregivers while providing objective information and
support throughout the care continuum focusing on the safe
transition of care.
- Perform functional assessments on a defined population of
patients using clinical skills and proprietary PAC management
workflow system and functionally based assessment technology tools.
Provide outcome targets to the appropriate audience.
- Utilize naviHealth proprietary technology and industry-standard
evidence-based tools for consideration of the appropriate level of
care, readmission risk, and needed interventions.
- Maintain nH Coordinate case documentation per established
- Collaborate effectively with patients' interdisciplinary health
care teams to coordinate an optimal transition plan to the most
appropriate PAC setting. The health care team includes physicians,
health plan UM/CM Nurse, hospital discharge planners, referral
coordinators, etc. The patient and caregiver are involved in the
decision-making process to minimize service fragmentation during
- Provide telephonic post-discharge support to assist the defined
population of patients in meeting short and long-term goals with
regards to their overall well-being. The TCC may collaborate with
other care team members such as home health providers to avoid
redundant telephonic follow up and coordinate care.
- Partner with acute and post-acute interdisciplinary care team
members to support discharge planning, resolve barriers, and
connect the patient to community resources and additional
- Assess and monitor patients' appropriateness for care setting
(as indicated) according to nH Predict, InterQual criteria and/or
industry standard evidence-based criteria. Communicate with
hospital case management and physicians on identified patients that
do not meet criteria and assist with developing appropriate
discharge setting as needed.
- Utilize knowledge of behavioral change science and principles
to guide patient/caregiver interventions.
- Address end of life issues including hospice and palliative
- Practice cultural competency with awareness and respect for
- Facilitate the development of a culturally sensitive
individualized transitional care plan for services that including
clinical, psycho-social, and environmental needs. Monitors and
evaluates the effectiveness of the plan. Make recommendations for
changes in the transitional care plan that incorporates
transitional needs, as indicated.
- Provide individualized evidence-based condition-specific
patient education directed at self-care and reduction of
exacerbations. Education is delivered at the appropriate health
literacy level in a culturally sensitive manner.
- Coordinate comprehensive post-discharge health care services,
support programs, and referrals for community-based services
- Review readmission reports, quarterly and other reports as
needed to assist with the identification of opportunities for
- Participate in weekly readmission and other type rounds as
needed based upon opportunities.
- Adhere to organizational and departmental policies and
- Maintain confidentiality of all PHI information in compliance
with HIPPA, federal and state regulations, and laws.
- Perform other duties and responsibilities as required,
assigned, or requested.
- Active, unrestricted Registered Nurse licensure required
- 3 - 5 years of clinical experience required
- At least 2 years of case management experience preferred
- Patient education background, rehabilitation, and/or home
health nursing experience a plus
- Experience working with geriatric population preferred
- Exceptional verbal and written interpersonal and communication
- Strong problem solving, conflict resolution, and negotiating
- Proficient with Microsoft Office applications including Word,
Excel and PowerPoint
- Independent problem identification/resolution and
- Must be able to prioritize, plan, and handle multiple
Work Conditions and Physical Requirements
- This role is performed onsite at facilities or telephonically
as directed by the manager
- Ability to establish a home office workspace
- Ability to manipulate laptop computer (or similar hardware)
between office and site settings
- Ability to view screen and enter data into a laptop computer
(or similar hardware) within a standard period of time
- Ability to communicate with clients and team members including
use of cellular phone or comparable communication device
- Ability to remain stationary for extended periods (1 - 2
- Travel requirements
- Ability to mobilize to and within sites within an assigned
local or regional market/area, including car transport, up to 85%
of the time
naviHealth is improving the healthcare experience for seniors to
live more fulfilling lives. For nearly a decade, naviHealth has
been a trusted partner for the nation's top health plans, health
systems, and at-risk physician groups navigating the shift from
volume to value. Powered by a predictive technology and decision
support platform that provides clinicians and care teams with
evidence-based protocols, naviHealth's high-touch, proven care
model fully supports patients from pre-acute through to the home.
With naviHealth, patients can enjoy more days at home, and
healthcare providers and health plans can significantly reduce
costs specific to unnecessary care and readmissions. For more
information about naviHealth, visit navihealth.com.
Improving the healthcare experience for seniors to live a more
Rooted in respectGuided by purpose Devoted to service Energized
The above statements are intended to describe the general nature
and level of work performed by colleagues assigned to this job. It
is not designed to contain or be interpreted as a comprehensive
list of all duties, responsibilities, and qualifications.
naviHealth reserves the right to amend and change responsibilities
to meet business and organizational needs as necessary.
naviHealth is an Equal Opportunity Employer. All qualified
applicants will receive consideration for employment without regard
to race, color, religion, sex, sexual orientation, gender identity,
national origin, protected veteran status, or any other protected
status under applicable laws and will not be discriminated against
on the basis of disability.
Keywords: NaviHealth, Westport , Transitional Care Coordinator, Other , Smithtown, Connecticut
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