The Transitional Care Coordinator position assists Heart of Ohio Family Health’s patients in transitioning from inpatient hospital and emergency department visits back to primary care. The goal of the position is to improve the continuity of care, reduce the 30-day readmission rate, and reduce unnecessary emergency department usage.

Reports to Behavioral Health Manager

Supervises Yes

Dress Requirement scrubs (nurse) or business casual (social worker) in accordance to Heart of Ohio Family Health’s dress code policy

Work Schedule F/T

Monday through Friday during standard business hours

Times are subject to change due to business necessity.

Exempt þ

Job Duties, these are considered essential to the successful performance of this position:

• Use multiple data sources (EPIC, Care Everywhere, hospital EHR systems, Clinisync, and payer provided patient information) to identify patients who have had inpatient and/or hospital or emergency department visits.
• Initiate and document timely outreach calls which are in alignment with TCM billing criteria. Connect patients to transitional care services with a primary care provider, OB/GYN, or behavioral health provide with in specified time frame depending on admission type.
• Provide basic education to postpartum patients such as: home visiting programs, contraception, safe spacing, safe sleeping.
• Provide basic education on appropriate ER use- When to go to ER, urgent care, or PCP.
• Review hospital records and discuss with patient post-discharge needs like durable medical equipment, medications, home healthcare, follow up care with specialists, and SDOH needs. Complete SDOH screenings with patients.
• Refer patients to internal providers/resources as needed such as PCP, behavioral health, in-house pharmacy, CHW’s, diabetes group, HTN group, etc.
• Record appointment dates and other relevant information in tracking spreadsheet. Tracking attendance of visits and intervening to improve visit attendance. Flagging charts of patients who are high utilizers.
• Consult with nursing or other medical staff as needed if pt has urgent medical questions or concerns outside scope of practice.
• Track billing codes used for follow-up visits. Collaborate with OSU billing dept as needed to notify of incorrect billing/billing codes and/or to clarify if a visit is eligible to be billed as TCM.
• Assist in providing education to providers surrounding criteria for billing TCM visits. This may include presenting at provider meetings, sending EPIC messages, or discussing face to face.
• Social workers who accept this position would be expected to assist clinic staff and patients in managing mental health crises or social crises (ex: domestic violence) as needed. This could include, but is not limited to initiating wellness checks, assessing for safety/safety planning, mandated reporting (CPS/APS), and de-escalation.
• Social workers who accept this position may be expected to provide brief psychosocial intervention/support to patients experiencing grief and/or fetal/infant loss.
• Other duties as assigned

Equipment Operated

Telephone

Computer

Printer

Fax machine

Copier

Other office equipment as assigned

Physical Demands and Requirements these may be modified to accurately perform the essential functions of the position:

• Mobility = ability to easily move without assistance
• Bending = occasional bending from the waist and knees
• Reaching = occasional reaching no higher than normal arm stretch
• Lifting/Carry = ability to lift and carry a normal stack of documents and/or files
• Pushing/Pulling = ability to push or pull a normal office environment
• Dexterity = ability to handle and/or grasp, use a keyboard, calculator, and other office equipment accurately and quickly
• Hearing = ability to accurately hear and react to the normal tone of a person’s voice
• Visual = ability to safely and accurately see and react to factors and objects in a normal setting
• Speaking = ability to pronounce words clearly to be understood by another individual

Job

Qualifications (Experience, Knowledge, Skills and Abilities)

• LPN, RN, LSW, LISW, LISW-S
• Experience in case management, utilization review, primary care, or hospital preferred. Experience in hospital discharge preferred.
• Experience working in an electronic health record/customer service.
• Ability to work with supervision and make decisions based on established policies and procedures
• Ability to successfully work in unison with others to create an efficient, harmonious work environment
• Demonstrates competency in working sensitively and respectfully with people of various cultures and social status
• Knowledge of federal, state and local laws and regulations pertaining to health care, confidentiality, and safety
• Ability to communicate (orally and in writing) in a professional manner
• Ability to maintain an established work schedule to ensure dependability and accuracy of work quality