Transitions of Care Coordinator; TOC) Care Coordinator, Clinician

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Aloha Care’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.

Aloha Care’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…