Transitions of Care Coordinator (TOC) Care Coordinator, Clinician

AlohaCare; Honolulu (HI); On-site; USD 61,000 - 80,000; Full time

Benefits offered by this job

401k employer contribution

Referral bonus

Pretax transportation and parking

Job summary

AlohaCare is seeking a Transitions of Care (TOC) Coordinator, Clinician to perform face-to-face assessments and telephonic TOCs for members preparing for hospital discharge. You will work with hospital teams, care navigators, and community resources to ensure safe, coordinated transitions.

The role emphasizes adherence to CMS and NCQA measures, accurate documentation in Guiding Care/G8, HIPAA compliance, and timely follow-up scheduling and transportation coordination post-discharge.

Qualifications

• Associate’s degree or professional license in healthcare field.
• Licensed RN, LPN, LSW, LMHC or LCSW in Hawaii.
• Minimum of 1 year of related clinical or managed care experience.

Responsibilities

• Complete face-to-face TOC assessments for hospitalized high-risk members.
• Coordinate with hospital case manager and floor nurse before bedside visit and review information.
• Perform activities supporting CMS and NCQA/HEDIS measures (TRC, FMC, FUH, FUM, FUA, IET).
• For FMC cases, review ED notifications, outreach and follow-up within required timeframes.
• Coordinate timely provider follow-up, transportation, and post-discharge handoffs.
• Maintain TOC documentation in Guiding Care/G8 and ensure HIPAA compliance.

Education

Associate’s degree in health care administration, Nursing, Social Work, Long Term Services and Supports, Public Health, Behavioral Health, or related field

Licensed RN, LPN, LSW, LMHC, or LCSW in the State of Hawaii

Job description

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Transitions of Care Coordinator (TOC) Care Coordinator, Clinician

AlohaCare’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Transitions of Care (TOC) Care Coordinator, Clinician is responsible for completing a face-to-face TOC Assessment with members prior to being discharged from the hospital and/or conducting a telephonic TOC Assessment as required. Also responsible for other Transitions of Care activities, referrals to Health Coordination, Behavioral Health, Disease Management, Care Navigators, Community Health Workers, Pharmacy and assistance with outreach to Resource Organizations as necessary.

The TOC Care Coordinator, Clinician works in collaboration with clinical operations staff, primary care providers and specialists, community resources, the members, family members and/or caregivers. Job functions with requirements of Med-QUEST, QUEST Integration, Medicare contractual performance policies and procedures and NCQA standards.

Primary Duties & Responsibilities:

• Complete face-to-face beside engagement for hospitalized members who are high-risk, assess and address discharge needs, reconcile medications, provide care-team information, and document and hand off follow-up care to the appropriate team.
• Conduct face-to-face and/or telephonic TOC assessments for members with complex admissions, readmissions, frequent emergency department utilization, or risk of becoming high-risk and complex.
• Coordinate with the hospital case manager or floor nurse before the bedside visit and review available clinical information, anticipated discharge disposition, and barriers to a safe transition.
• Perform activities supporting applicable CMS and NCQA/HEDIS measures, including Transitions of Care (TRC), Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC), Follow-Up After Hospitalization for Mental Illness (FUH), Follow-Up After Emergency Department Visit for Mental Illness (FUM), Follow-Up After Emergency Department Visit for Substance Use (FUA), Initiation and Engagement of Substance Use Disorder Treatment (IET), and readmission-related monitoring, consistent with current specifications.
• For assigned Medicare FMC cases, review ED notifications, initiate timely outreach, reinforce discharge instructions, assist with provider follow-up within the required timeframe, conduct provider verification when member outreach is unsuccessful, and document completed and attempted activities.
• For behavioral health or substance use transitions, coordinate timely qualified provider follow-up, treatment access, transportation, outreach, and handoffs.
• Following discharge, provide additional oversight and coordination for members relocated from institutions, including nursing facilities and hospital waitlist beds, for at least three months when required to stabilize the transition and reduce facility readmission risk.
• Interacts with members, family, provider(s) utilizing clinical and social knowledge and expertise to determine the member’s status and capacity to assess the options for service delivery.
• Assist member with scheduling the PCP and/or Specialist post discharge follow-up appointments, transportation, and DME needs post hospitalization.
• Provides individual member education on preventative health care measures and on medication education and compliance.
• Upon member discharge, ensure PCP/Specialist has current member information to include the discharge instruction, discharge summary, current medication list and other information requested.
• Conduct a follow-up phone call with member and/or caregiver for post discharge, conduct an appointment reminder call after the scheduled PCP/ Specialist follow-up appointment, and as needed throughout the TOC 30 Day Program.
• Assist member with outreach to Community Health Centers, primary care provider for BH/SUD, and/or Specialist as needed.
• If necessary, refer members to Health Coordination, Behavioral Health Peers Supports, Disease management, Care Navigators, Community Health Workers and Pharmacy departments when additional assistance is required.
• Maintains accurate and up to date written documentation and records of TOC activities in information system (Guiding Care/G8) according to appropriate TOC and/or clinical guidelines.
• Ensures compliance with all state and federal regulations, including HIPAA standards of confidentially protected health information, reporting of critical incidents, and reporting of quality-of-care issues.
• Participate in TOC Care Coordination staff meetings, interdisciplinary care team meetings, trainings, in-services, and Daily Inpatient Rounds as required.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, state and federal laws, and rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• Associate’s degree in health care administration, Nursing, Social Work, Long Term Services and Supports, Public Health, Behavioral Health, or related field or equivalent combination of education and experience.
• Licensed RN, LPN, LSW, LMHC, or LCSW in the State of Hawaii.
• Minimum of 1 year of related work experience in a clinical setting and/or in a managed care environment, behavioral health case management, health plan experience, or other related work experience.
• Experience with performing post-inpatient transition of care activities.
• Ability to network with other providers for successful transition from inpatient to community-based services.
• Prior experience in clinical assessments, discharge planning, and utilization management.
• Ability to work with varied teams/professionals for inter-disciplinary case consultation and discharge planning.
• Knowledge of local resources, providers, and referral processes.
• Support AlohaCare’ s corporate core values in all interactions.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
• Possesses excellent time management and organizational skills; dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Possession of a valid driver's license with access to a reliable automobile.
• TB Clearance
• First Aid and CPR Certification

Preferred Requirements:

• Experience with QUEST and Medicare programs and working knowledge of managed health care field.
• Experience with individuals who are low-income or have special health care needs, including: HIV/AIDS, developmental disabilities, medical -fragile, older adults, and individuals with physical disabilities.
• Knowledge of local resources, providers, and referral processes.
• May require prolonged sitting- up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday?

Salary Range: $61,000 - $80,000 annually

AlohaCare is committed to providing equal employment opportunities to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.