TOC Care Management Coordinator

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

• Location 1240 39th Street,Brooklyn, NY, 11218,United States
• Base Pay $22.00 - $26.00 / Hour
• Employee Type Full Time
• Required Degree 2 Year Degree

Description

Job Summary:

The Transitions of Care (TOC) Coordinator manages daily patient admissions and discharges, ensuring timely communication and documentation across healthcare facilities to support continuity of care. This role involves tracking patient movement, coordinating with providers, managing system documentation in Guiding Care, and ensuring regulatory compliance with HEDIS and CMS guidelines.

• Reconcile RHIO and Hamaspik Central alerts daily to identify Emergency Department, Observation, Inpatient, Skilled Nursing Facility (SNF), Behavioral Health, and Rehabilitation admissions and discharges.
• Distribute daily admission and discharge notifications to the Medicare TOC Team and Utilization Management.
• Monitor admissions and discharges throughout the day and communicate significant updates to the TOC team.

Care Coordination

• Contact hospitals, Skilled Nursing Facilities (SNFs), rehabilitation centers, and other facilities to obtain member status updates.
• Monitor anticipated discharge dates and communicate discharge readiness to the assigned TOC RN.
• Notify the TOC RN of changes in member status, barriers to discharge, and important clinical updates requiring intervention.
• Coordinate with facility staff to obtain discharge plans and discharge disposition.
• Schedule timely post-discharge appointments with Primary Care Providers (PCPs).
• Schedule specialty appointments as requested to support continuity of care.
• Coordinate communication between facilities, providers, TOC Nurses, Care Managers, Utilization Management, and other interdisciplinary team members.
• Assist in removing barriers that may delay discharge or impact a successful transition back to the community.
• Support continuity of care by ensuring appropriate follow-up services are coordinated after discharge.

Guiding Care Documentation

• Create, update, and close Service Interruptions (SI) for Emergency Department, Observation, Inpatient, SNF, Behavioral Health, and Rehabilitation stays.
• Complete MAP and DSNP Hospitalization/SNF/Behavioral Health Admission Notification scripts accurately and within required timeframes.
• Verify facility information using NPPES and authorization records.
• Maintain complete, accurate, and timely documentation within Guiding Care.

Provider Notifications

• Prepare and fax Notifications of Admission (NOA), Transfers, and Discharges to Primary Care Providers within required timeframes.
• Upload notifications and fax confirmations into Guiding Care.
• Obtain missing PCP contact information when necessary.
• Ensure discharge summaries and supporting documentation are forwarded to PCPs in accordance with HEDIS Transitions of Care requirements.
• Request and obtain discharge summaries from hospitals and facilities.
• Perform ongoing follow-up until discharge summaries are received.
• Review discharge summaries to ensure required HEDIS Transitions of Care elements are present.
• Coordinate with TOC Nurses and Utilization Management regarding missing or incomplete discharge documentation.
• Ensure discharge documentation is distributed timely to PCPs.

Internal Workflow Coordination

• Generate and assign activities for interruption of services during inpatient admissions.
• Generate notification of change in member status activities to assigned Care Managers.
• Generate resumption of services activities following member discharge.
• Coordinate with Authorization, DME, Home Care, Transportation, Vendor Management, and other internal departments to ensure services are suspended and resumed appropriately.

Quality & Compliance

• Maintain and update the HEDIS Transitions of Care (TRC) tracker accurately and in real time.
• Ensure all TRC components, including Notifications of Admission, Notifications of Discharge, PCP notifications, discharge summaries, and supporting documentation, are entered completely and accurately.
• Monitor TRC compliance timelines to ensure all required activities are completed within established regulatory and organizational timeframes.
• Review the tracker daily for completeness, identify outstanding items, and follow up to resolve missing documentation or overdue tasks.
• Collaborate with TOC Nurses, Care Managers, Utilization Management, and other departments to obtain information needed to maintain an accurate and compliant TRC tracker.
• Support HEDIS, CMS Star Ratings, and internal quality initiatives by ensuring the accuracy, timeliness, and integrity of all TRC data and documentation.
• Identify discrepancies, trends, or potential compliance risks and elevate issues to leadership promptly.
• Participate in quality audits and process improvement initiatives to enhance the accuracy and efficiency of the Transitions of Care program.

Required Skills

• Excellent organizational and time management skills.
• Strong communication and interpersonal skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong attention to detail and documentation accuracy.
• Knowledge of Medicare Advantage, DSNP, and Managed Long-Term Care workflows.
• Experience with RHIO, Guiding Care, Hamaspik Central, and electronic medical records.
• Ability to work collaboratively with interdisciplinary teams, providers, hospitals, and community partners.