Transition of Care Coordinator
Total Care Connect (TCC) is a mobile integrated health organization delivering in-home clinical and preventive care to members across Ohio and surrounding regions. The Transition of Care Coordinator is responsible for reviewing daily hospital discharge notifications, triaging member needs, and coordinating timely post-discharge visits to ensure a safe transition for members returning home after hospitalization.
Responsibilities
- Review daily ADT/discharge alerts to identify eligible members
- Assess discharge diagnoses, risk level, and clinical appropriateness for TCC services
- Prioritize outreach based on clinical needs and post-acute risk factors
- Determine the appropriate intervention pathway
- Conduct initial outreach to recently discharged members
- Confirm discharge details, evaluate immediate needs, and assess potential barriers to care
- Coordinate with the Care Coordination team to ensure visits are scheduled within required timeframes (24–72 hours)
- Support members with education, planning, and navigation during early post-discharge periods
- Serve as a clinical liaison to health plan case managers, hospital teams, and discharge planners
- Provide status updates and close-loop communication back to referral partners
- Ensure accurate documentation in TCC’s care platform and maintain program compliance
- Assist in building and improving TOC workflows, SOPs, and process standards
- Monitor TOC metrics including engagement rates, timeliness of visits, and readmission risk indicators
- Collaborate across internal teams to improve operational effectiveness
Skills
- Licensed Practical Nurse (LPN)
- Medical Assistant (MA) with strong post-acute or hospital experience
- Experience in Case Management
- Experience reviewing ADT feeds or discharge summaries
- Familiarity with Medicaid and DSNP populations
- Experience in home-based care, case management, community paramedicine, or value-based care
- Strong communication and documentation skills
Company Overview