Transitional Care Coordinator - Temporary - (On-site, Salinas, CA)

01 Salinas Valley Health Medical Center; Salinas (CA); On-site; USD 207,598,809 - 234,192,000; Full time

Job summary

01 Salinas Valley Health Medical Center is seeking a Transitional Care Coordinator to ensure smooth transitions for discharged patients. The role involves coordinating with physicians, social workers, and families to reduce readmissions and improve outcomes.

The TCC will follow a patient‑centered plan across home programs and clinic settings, providing education, monitoring, and timely follow‑ups for up to 30 days post discharge.

Qualifications

• Associate degree in nursing required; BSN preferred.
• Current California RN license required; BLS required.
• Three (3) years of nursing experience required; knowledge of post‑acute care coordination and case management principles.

Responsibilities

• Assess, evaluate, and implement a plan of care with physicians, hospital teams, and families.
• Develop a Continuum of Care plan with leadership, social work, and case management.
• Follow up with patients to ensure adherence to medical treatment plans.
• Meet eligible patients in the transition program, including virtual home program patients, as needed.
• Identify barriers and needs to outpatient care and support.
• Call patients within 24–48 hours post discharge to identify barriers and coordinate resources.
• Provide daily phone or video follow‑ups for virtual patients during the program.
• Triages patients using clinical judgment for urgent care or ER referral.
• Serve as a resource and educator for patients and families for 30 days post discharge.
• Intervene to reduce avoidable ER visits and readmissions.
• Provide disease‑specific education through in‑person, telephonic, or virtual means.
• Monitor vital signs and educate on equipment use and schedules.
• Document all interactions and care plans in the EHR.
• Facilitate follow‑up appointments with PCPs and specialists.
• Collaborate with leadership to address barriers as needed.

Skills

Bilingual Spanish

Case management

Electronic Health Records

Education

Associate degree in nursing

BSN preferred

Tools

EHR system

Job description

Position Summary

Transitional Care Coordinator (TCC) will be employed and payrolled by a third‑party staffing partner. The TCC ensures smooth transitions of care for patients discharged from the hospital, working with population‑specific, clinic‑specific, insurance‑specific, high‑risk, or virtual home program patients to reduce readmissions, improve outcomes, and enhance satisfaction.

Responsibilities

• Assess, evaluate, and implement a plan of care for the patient in collaboration with physicians, hospital care teams, and families.
• Work with the Transitional Care Program Leadership team, Social Worker, Case Management staff, and multidisciplinary team to develop a Continuum of Care plan.
• Follow up with patient and support structure to ensure compliance with medical treatment plans.
• Meet with eligible patients in the transition program, including virtual home program patients, in the Emergency Room when needed.
• Introduce the program and identify barriers or needs to outpatient care/support.
• Call patients within 24–48 hours post discharge (12–18 hours for virtual home patients) to identify barriers and facilitate resources.
• Provide daily phone or video calls for virtual home patients throughout the specified program timeframe.
• Utilize clinical judgment to triage patients, decide on urgent care or emergency room visits, remote management, or referral to other providers.
• Serve as a resource and educator to patients and families for a minimum of 30 days post discharge.
• Intervene on behalf of the patient and organization to reduce avoidable ER visits or readmissions.
• Provide disease‑specific patient education, including medication education, via in‑person, telephonic, or virtual modalities.
• Monitor vital signs, reinforce equipment use, and educate on vital‑sign schedule.
• Record relevant data, alert healthcare team to critical changes, and track/report lab or diagnostic results.
• Evaluate patient condition, diagnoses, medications, and support systems to formulate an individualized plan.
• Document all patient and family interactions, assessments, interventions, and care plans in the electronic health record.
• Facilitate follow‑up appointments with PCPs and specialists.
• Collaborate with Leadership and Social Worker when barriers are identified and action is needed.

Qualifications & Experience

• Associate degree in nursing required; Bachelor's of Science in Nursing (BSN) preferred.
• Current California Registered Nurse license required.
• Current BLS/Healthcare Provider status per American Heart Association standards required.
• Three (3) years of nursing experience required.
• Knowledge of community resources, post‑acute care coordination, and case management principles required.
• Bilingual in Spanish preferred.
• Case Management experience preferred.
• Broad general nursing knowledge and ability to navigate a computerized medical record system.

Pay & Benefits

The hourly rate for this position starts at $72.45. The range displayed on this job posting reflects the target for new hire salaries for this position.

Job Specifications

• Union: Non‑Affiliated
• Work Shift: Day Shift
• FTE: 1.0
• Scheduled Hours: 40