Transitional Care Coordinator, Praxis Health

Praxis Health; Bend (OR); Remote; Full time

Job summary

An established industry player is seeking a dedicated Transitional Care Management Coordinator to enhance patient experiences during their transitions from hospital to home. In this vital role, you will advocate for patients, ensuring they receive timely follow-ups and coordinated care. Your expertise will help address barriers to effective healthcare, while your compassionate approach will guide patients through their healthcare journeys. Join a family of medical groups committed to delivering high-quality care across Oregon, and be part of a culture that values collaboration and innovation in healthcare solutions.

Qualifications

• 2+ years of direct patient care experience in clinical settings.
• RN or LPN license required, with a focus on transitional care.

Responsibilities

• Act as a patient advocate, ensuring timely follow-ups with PCPs.
• Coordinate care between healthcare organizations and support medication management.

Skills

Compassionate patient-centered care

Exceptional communication skills

Organizational skills

Motivational Interviewing techniques

Understanding of medical terminology

Education

High school diploma or GED

Licensed Practical Nurse (LPN) or Registered Nurse (RN)

Basic Healthcare BLS certification

Tools

Microsoft Office Suite

Electronic Medical Records (EMR)

Job description

Job Description

Join Our Team as a Transitional Care Management (TCM) Coordinator!Location: Remote (Oregon residents only)Schedule: Full-time, Monday - Friday

Starting Pay: $30 - $37/hour, depending on experience

Praxis Health is looking for a passionate Transitional Care Management (TCM) Coordinator to guide patients through seamless transitions from hospital stays or ER visits back to their primary care providers. You’ll be a vital connection in ensuring patients get the right care, at the right time, with the highest quality.

What You’ll Do:

• Act as a patient advocate, navigating their healthcare journey.
• Ensure timely follow-ups with Primary Care Providers (PCPs).
• Coordinate care between healthcare organizations, hospitals, and specialty providers.
• Work with the Quality team to achieve the best outcomes for patients.
• Support medication reconciliation and management.
• Identify and address barriers to effective patient care.

What You Bring:

• A heart for compassionate, patient-centered care.
• RN or LPN license (or qualifications to obtain one).
• Proven experience in transitional or coordinated care is a bonus.
• Exceptional communication and organizational skills.

Minimum Qualifications

Required Education

• High school diploma or GED.
• Licensed Practical Nurse (LPN) or Registered Nurse (RN) from an accredited institution, community college, or university.
• Basic Healthcare BLS certification.
• Solid understanding of medical terminology and managed care.

Required Experience

• Clinical Experience: At least 2 years of direct patient care in a clinical or hospital setting.
• Healthcare Background: Minimum 3 years in a healthcare, health plan, or related field.

Preferred Experience

• Proficiency in Motivational Interviewing techniques.
• Communicating effectively with patients over the phone.
• Strong computer skills, including Microsoft Office Suite (Word, Outlook, Teams, Excel).
• Expertise in chronic disease management, case management, utilization management, and adult acute care.
• Hands-on experience with Electronic Medical Records (EMR) systems.
• Familiarity with ICD and CPT coding.

Knowledge, Skills & Abilities

• Comprehensive understanding of organizational policies, regulations, and procedures to deliver excellent patient care.
• Proficiency with medical equipment and instruments, and awareness of safety hazards to ensure a safe work environment.
• A team-oriented mindset: self-disciplined, energetic, innovative, and passionate about achieving shared goals.
• Ability to maintain confidentiality in all aspects of patient care, adhering to state and federal regulations.
• Strong communication skills to confidently engage with community healthcare organizations and personnel.
• Ability to work independently within the scope of practice, demonstrating sound judgment and reliability.

About Us

Praxis Health is a family of medical groups providing high quality healthcare throughout the state of Oregon. Our community-based clinics are the DNA of our business, providing better medicine, advocacy for our patients, and a satisfying and collaborative culture for our providers and staff.

The Praxis family approach is dynamically different than other healthcare companies in Oregon. We are not “big box” health care, but rather a company of small groups and clinics, of nimble micro-cultures that can quickly adapt to industry changes, as well as patient needs.

We have been serving communities across the beautiful and adventurous state of Oregon for over 50 years! And we are pioneers and thought leaders in the industry. Our commitment to innovative and operational excellence has allowed us to create healthcare solutions that are both cost-efficient and cutting edge.

Come see how healthcare is done right!

General Physical Requirements

Physical Demands:

• Manual dexterity for office machine operation including computer and calculator; stooping, bending to handle files and supplies, or sitting for extended periods of time.
• Stress can be triggered by multiple staff demands and deadlines.

Work Environment:

Home office.

Equal Opportunity Statement

EOE Disabled/Veteran

Praxis Health is an Equal Opportunity Employer and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.