Care Transitions Architect

City of Lincoln; New York (NY); On-site; USD 30,000 - 36,000; Full time

Job summary

The Transitions of Care (TOC) Coordinator at City of Lincoln oversees patient admissions and discharges, ensuring timely communication across facilities and accurate documentation in Guiding Care. This role supports continuity of care, coordinates with hospitals, SNFs, and PCPs, and ensures compliance with HEDIS and CMS guidelines.

Responsibilities include reconciling alerts, distributing notifications to TOC teams, monitoring discharge readiness, arranging post-discharge follow-ups, and

Qualifications

• Requires 2 year degree.
• Experience with RHIO, Guiding Care, and electronic medical records (EMR).
• Knowledge of Medicare Advantage, DSNP, and managed long-term care workflows.

Responsibilities

• Manage daily patient admissions and discharges with timely communication across facilities.
• Coordinate with hospitals, SNFs, rehab centers, and other providers for member updates.
• Notify TOC RN of status changes and discharge barriers needing intervention.
• Schedule post-discharge follow-ups with PCPs and specialists as needed.
• Maintain accurate TRC tracker and ensure compliance with HEDIS/CMS guidelines.

Skills

Organization

Communication

Multitasking

Attention to detail

Medicare knowledge

Interdisciplinary teamwork

Education

2 Year Degree

Tools

RHIO

Guiding Care

Hamaspik Central

EMR

Job description

The Transitions of Care (TOC) Coordinator at City of Lincoln oversees patient admissions and discharges, ensuring timely communication across facilities and accurate documentation in Guiding Care. This role supports continuity of care, coordinates with hospitals, SNFs, and PCPs, and ensures compliance with HEDIS and CMS guidelines.

Responsibilities include reconciling alerts, distributing notifications to TOC teams, monitoring discharge readiness, arranging post-discharge follow-ups, and