Transitional Care Coordinator is responsible for facilitating transitional/post-acute services for patients. Transitional Care Coordinators support the patients through timely, high quality, and efficient health care which includes all transitional/post-acute support services and the Home Wellness Department through the comprehensive adherence to the multi-disciplinary care plan, patient self-management goals and referrals to both internal and external resources.


a. Provide phone support to all transitional/post-acute teams and the Home Wellness Department through inbound/outbound call management and inhome support of all patient needs.
b. Provide explanation of all services and obtain verbal consent from patients for the transitional/post-acute and Home Wellness Departments.
c. Coordinate and manage schedules for the transitional/post-acute and Home Wellness Departments in accordance with contracted agreement of all health plans and referring providers.
d. Contact patients in a timely manner, and obtain required documentation of CSA, and schedule for the transitional/post-acute team and Home Wellness Department.
e. Act as a liaison with the referral sources, transitional/post-acute team, Home Wellness Department, and health plans for coordination of orders, supplies, appointments, and medical records.
f. Obtain requested medical records in a timely manner.
g. Upload all orders, field documents, and requested records to the patient’s charts for the transitional/post-acute team and Home Wellness Department.
h. Communicate test results and the execution and/or communication of care plans to patients/families, under the direction of the Nurse Practitioners.
i. Provide relevant self-management support for patients with chronic illnesses as identified by clinical teams through inbound and outgoing call management within their scope of practice.
j. Work collaboratively with all departments, health plans, and provider partners to ensure timely, comprehensive exchange of information and personalized care for all patients.
k. Utilize the system navigator for ongoing contact with patients and families allowing them direct access to address questions and/or concerns and escalate needs to the appropriate clinical support staff.
l. Obtain and collect data required by contracted partners to ensure timely and obligated requirements are met for all transitional/post-acute teams and Home Wellness Departments.
m. Demonstrate excellence and accuracy in collection of information, knowledge of processes, and be committed to providing outstanding customer service.
n. Understand and effectively communicate HIPAA compliance, corporate compliance, and client confidentiality.
o. Ensure compliance with local, state, and federal regulations.
p. Adhere to the National Patient Safety Goals as defined by Joint Commission.
q. Complete other duties as assigned.



a. Know and follow Employee Handbook policies and procedures.
b. Communicate verbally and in writing through proper channels.
c. Maintain patient confidentiality. Be HIPAA compliant by observing HIPAA and group’s guidelines.
d. Use time clock appropriately.
e. Participate in staff meetings.
f. Follow dress code.
g. Notify supervisor in writing when requesting paid time off.
h. Be courteous.
i. Be flexible and adaptable.
j. Promote departmental and organizational goals.
k. Know and follow applicable safety standards.



a. Work Position:

i. Sitting – 90%
ii. Standing – 5%
iii. Walking – 5%

b. Body Movements:

i. Lifting 0-20-pounds; books, reams of paper, files, etc.- 5%
ii. Bending, stooping and squatting- 5%
iii. Reaching above head to 75 degrees less than- 5%
iv. Grip/hand dexterity; writing – 80%
v. Climbing stairs- 5%



a. Language & Communication Skills:

i. Must be fluent in both spoken and written English and maintain professionalism in all verbal and written correspondence with both internal and external clients.

b. Decision Making:

i. Makes appropriate decisions for incoming and outbound member issues, consult, and appropriately request assistance from Supervisory team when necessary.

c. Computer Skills:

i. Able to utilize necessary programs to ensure effective communication and collection of required member chart data; including but not limited to: Microsoft products, Carepointe, and other software as necessary.

d. Problem Solving:

i. Must maintain appropriate problem-solving skills, with the ability to operate independently, and provide necessary and appropriate support to the field based clinical teams.



a. High school diploma or GED required, some college or medical certification preferred.
b. Previous customer service knowledge preferred.
c. MA, CNA or former medical office experience preferred.
d. Knowledge of medications, medical terminology and patient care preferred.
e. Maintain ongoing education as requested to support position.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time. The above expectations have been explained and discussed with me. I understand that my performance will be evaluated based upon these expectations.

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