Full-Time About the Role We are seeking a detail-oriented Transitions of Care Coordinator for a full-time hybrid position based in Spring Valley, NY. In this role, you will monitor member admissions and discharges across acute and post-acute settings, communicate real-time updates to clinical teams, coordinate post-discharge care, and help eliminate barriers to support safe, seamless transitions back to the community.
Reconcile daily Regional Health Information Organization (RHIO) alerts to track admissions and discharges across Emergency Department, Observation, Inpatient, Skilled Nursing Facility (SNF), Behavioral Health, and Rehabilitation settings.
Notification & Communication:
Distribute daily admission and discharge notifications to the TOC Team and Utilization Management; monitor status changes throughout the day and communicate significant member updates.
Facility Outreach:
Contact hospitals, SNFs, rehabilitation centers, and other care facilities to obtain member status updates, anticipated discharge dates, discharge readiness, and disposition details.
Clinical Collaboration:
Notify assigned TOC RNs of status changes, clinical updates requiring intervention, and discharge barriers. Coordinate communication between facilities, providers, TOC Nurses, Care Managers, and Utilization Management.
Appointment Scheduling:
Schedule timely post-discharge appointments with Primary Care Providers (PCPs) and specialty care providers as requested to support continuity of care.
Care Support & Barrier Removal:
Assist in identifying and eliminating barriers that may delay discharge or impact a successful transition back to the community, ensuring follow-up services are coordinated.
System Documentation:
Create, update, and close Service Interruptions (SI) for Emergency Department, Observation, Inpatient, SNF, Behavioral Health, and Rehabilitation stays.
Schedule & Location Requirements Work Location:
Hybrid schedule based out of Spring Valley, NY .
Work Schedule:
Full-Time (Onsite Monday through Thursday; Remote on Fridays ). Qualifications & Skills Category Description Location & Schedule Must be able to commute to our Spring Valley, NY office Mon-Thu, with the ability to work remotely on Fridays. Required Skills Strong organizational, time management, and multi-tasking skills Excellent verbal, written, and interpersonal communication skills High attention to detail with a strong focus on accurate documentation Knowledge of Medicare Advantage, D-SNP, and Managed Long-Term Care (MLTC) workflows Experience using RHIOs, GuidingCare, Electronic Medical Records (EMRs), and health info systems Ability to collaborate with interdisciplinary teams, providers, and healthcare facilities Proficiency in Microsoft Excel and Microsoft Word Preferred Skills Associate's or Bachelor's degree in Healthcare Administration or related field 1+ years of experience in healthcare operations, health plan care management, or TOC Prior remote work experience Familiarity with HEDIS Transitions of Care (TRC) measures Experience supporting complex or dual-eligible populations
For California Applicants:
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA). This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
