Care Transition Coordinator II, Care Management - 25-79

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees.  We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

The CTC provides advanced administrative support by facilitating pre and post-acute care needs to avoid readmissions and ER visits. Serves as a liaison between hospital clinicians, providers, vendors, nursing facilities and HPMG Care Management staff. Capable of handling nonclinical activities within the full scope of Inpatient, Welcome Home, and Case Management functions as noted in the below “Essential Responsibilities” with a primary focus in one of these areas. Practices skills in the other two functional areas at least once a quarter or when asked of them. Duties such as: processing authorizations for discharge needs, scheduling PCP and specialist appointments, coordination of care at the bedside and PCP offices, and referring patients to appropriate Case Management staff. Monitors and tracks issues received to assure timely resolution and feedback communication to the referral source.

Job Responsibilities:

Inpatient

• Completes intake process – facesheet receipt, verifies eligibility and builds referral into authorization, attaches clinical records and routes authorization to appropriate clinical queue within TAT requirements.
• Verifies benefit details with the health plans.
• Calculates LACE score at time of admission and documents in the authorization.
• Assists nursing staff in obtaining clinical information from facilities and summarizes information for continuing nursing facility stays, processes letters as directed by the CCR/TOC nurses, and processes authorizations which require only administrative level of review.
• Serves as contact to receive and process authorizations needed to support timely discharge from hospital or nursing facilities and subsequently routes cases to the appropriate care team. 
• Engages patient and caregivers upon admission to the hospital and throughout the hospital stay, discharge instructions, transition preparedness, follow-up appointments within 7 days of discharge, and care to assure the patient understands the treatment plan and is well prepared for transition to the next level of care, in coordination with the TOC/CCR nurse.
• Shares the treatment/discharge plan created by the TOC nurse with member and appropriately communicates information so the patient is well prepared for transition to the next level of care.
• Participates in physician/case management/concurrent review rounds as needed.
• Completes ad hoc health plan drilldown requests.
• Travels to hospitals in assigned regions in Sacramento, San Joaquin or the Bay Area, up to 100% of the time.
• Maintains client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards. 
• Performs other duties as assigned.

Welcome Home

• Receives in-basket notification of discharge and/or identifies discharge from hospital EMR, calculates discharge LACE score and routes case to appropriate team member following episode creation.
• Uploads discharge summaries, medication list and other documentation to the Welcome Home episode in Epic.
• Completes initial Welcome Home call to member within 36 hours for appropriate LACE score and refers high risk cases to Welcome Home nurse.
• Follows up and addresses any needs identified during outreach call.
• Sends letters externally as appropriate.
• Collaborates with interdisciplinary team via telephonic outreaches to support implementation of the identified discharge plan.
• Makes PCP follow-up appointment as soon as possible after discharge with primary care doct