Transition of Care Coordinator

Honest Medical Group
Health Management
1 to 3 years
28 Jun 2024

About the job

Who You Are

You are devoted, compassionate, and enjoy being on the front lines in healthcare, changing the lives of your patients. You are passionate about getting to the root cause of a patient’s conditions, removing social determinants of healthcare, and ensuring the highest possible quality of life for those in your care. You don’t want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your patients that you would to your own family member.

Does this sound like you? If so, we should talk.

Who We Are

We are Honest Medical Group, a groundbreaking team of health care professionals focused on making a major impact in health care. At Honest, we align every aspect of our company to support patients and providers. We are devoted to purpose and inspired by innovation. We embrace our communities and lead with kindness. We drive health improvements, create a seamless member experience, and eliminate unnecessary cost. We listen to the needs of our patients and our employees—continually working to push beyond the status quo.

For us, it’s all in an Honest day’s work.

Your Role

The Transition of Care (TOC) Coordinator is a member of our interdisciplinary team (IDT) and is responsible for supporting the development and execution of patient care transition plans as they progress from the acute or post-acute care setting to the home environment. The position will directly contribute to improving patient health outcomes, reducing the total cost of care, and reducing unnecessary care and readmissions to the acute or post-acute setting. This role will establish and build relationships with community hospitals and post-acute care settings including but not limited to discharge planners at hospitals, acute rehabilitation, sub-acute rehabilitation, behavioral health settings, primary care practices, and home health agencies.

Primary Functions Include:

  • Develop and maintain strong relationships and partnerships with acute care settings, post-acute care settings, and community-based healthcare organizations.
  • Collaborate with discharge planners to ensure transitional discharge plans are in place. Facilitate and schedule post discharge visits with either the patient’s primary care provider (PCP) or an Honest Advanced Practice Provider (APP).
  • Utilize the health information exchange and other resources (for example, Bamboo Health) to obtain discharge summaries, as needed, and to monitor the movement of patients between settings.
  • Communicate with patients and caregivers before and during the discharge phase to ensure coordination of care.
  • Collaborate with Honest leadership to ensure an aligned approach to relationship-building with providers and healthcare organizations in the community.
  • Regularly engage with high-volume acute and post-acute settings to round, both in person and via telephone.
  • Escalate clinical issues and urgent needs to the care team and provide daily updates on the census to primary care providers and care management teams.
  • Remain responsible for tracking and trending responsibility areas of the transition of care process.
  • Ensure that post-discharge appointments are scheduled and that they occurred.
  • Document all patient encounters in the appropriate locations.
  • Travel to or between local worksites up to 50% of the time.
  • Perform related responsibilities as required.

How You Qualify

You reviewed the Who You Are section of this job posting and immediately felt the need to read on. That makes you a match for our innovative culture. You have experience in a healthcare environment, with demonstrated examples of service excellence. You reviewed the essential qualifications section of this job description and believe that you have what it takes to be successful in the position.

  • Associate degree in health care, human services or a related healthcare field or at least two recent years of healthcare experience required
  • Licensed Practical or Vocational Nurse experience preferred
  • Experience in building relationships, community collaboration, and providing education preferred
  • Sales experience helpful, but not required
  • Must be able to arrange and consistently travel to various work sites, as well as possess and maintain a valid driver's license in your state of residence and motor vehicle insurance
  • Ability to effectively communicate preventive health, health education, and health management philosophies to patients/caregivers and agencies
  • Knowledge and understanding of medical terminology, direct contracting, and value-based care
  • Strong computer skills: ability to run reports, merge data sets, sort
  • Skilled in using computer-based programs: Microsoft Office (Outlook, Word, Excel, PowerPoint) or equivalent, Internet searches, electronic health records, etc.
  • Ability to quickly establish a rapport and build trusting relationships with others
  • Extremely organized

How You Are Supported

  • As a full-time team member, you will benefit from Honest’s exceptional total rewards package, including competitive base pay with bonuses, paid time off starting at 4 weeks for full time employees, 12 paid holidays per year, reimbursement for continuing medical education, 401k with match, health, dental, and vision insurance.
  • As a part-time team member, you will benefit from Honest’s total rewards package, including competitive base pay with bonuses, pro-rated paid time off, paid holidays, reimbursement for continuing medical education, 401k with match.
  • Family friendly policies that support paid parental leave and flexible work arrangements
  • As a team member you’ll be supported by our robust commitment to training and development that starts with onboarding and continues throughout your career with Honest
  • You will collaborate with like-minded healthcare professionals who, like you, understand the importance and value of Honest’s high-quality, value-based, care model.

Honest is an equal opportunity employer that is committed to inclusion and diversity. We take affirmative action to ensure equal opportunity for all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics.

Honest is committed to working with and providing reasonable accommodations to job applicants with physical or mental disabilities. Applicants with a disability who require a reasonable accommodation for any part of the application or hiring process should email [email protected] for assistance. Reasonable accommodation will be determined on a case-by-case basis.

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