Transitional Care Management (TCM) Care Coordinator

Description

North Olympic Healthcare Network (NOHN) 

Job Title: Transitional Care Management (TCM) Care Coordinator  

Department: Nursing Services  

Reports To: Care Management Nurse Supervisor 

FLSA Status: Non-Exempt 

Summary: 

The Transitional Care Management (TCM) Care Coordinator is a key member of the medical team responsible for ensuring that patients receive timely and appropriate medication refills while also supporting the seamless transition of patients from hospital to home. This role combines both medication management and transitional care duties to improve patient outcomes and enhance the quality of care. The Coordinator will work closely with patients, healthcare providers, and care teams to ensure that patients understand their treatment plans, stay on track with medications, and receive the necessary follow-up care after discharge. 

Essential Duties and Responsibilities: 

Medication Refill Management:  

• Medication Refill Processing: 

  • Receive and review patient requests for medication refills via phone, EMR, or fax. 
  • Verify patient information, medication history, and prescription details before authorizing refills. 
  • Communicate with pharmacies to ensure that refills are processed correctly and in a timely manner. 
  • Alert the prescribing physician if any issues arise regarding refills or if the patient needs an updated prescription. 

• Patient Communication: 

  • Contact patients to confirm medication refill requests and provide any necessary education about their prescriptions. 
  • Ensure that patients have adequate medication and understand dosage, instructions, and any necessary follow-up appointments for ongoing management. 

• Prescription Coordination: 

  • Work with the physician to ensure that all refills comply with the patient’s care plan and treatment goals. 
  • Help maintain an up-to-date list of all patient medications in the office’s electronic health record (EHR) system. 
  • Monitor medication adherence and report any concerns to the physician if discrepancies or issues arise. 

Transitional Care Management:  

• Post Discharge Follow-Up: 

  • Contact patients within 48 hours of hospital discharge to conduct a follow-up assessment, ensuring they understand their discharge instructions and next steps in their care plan. 
  • Review discharge paperwork with the patient, including medication lists, follow-up appointments, and any referrals. 

• Care Coordination and Appointment Scheduling: 

  • Help schedule necessary follow-up appointments with the physician or specialists, and assist patients in accessing any needed services (e.g., home health care, physical therapy). 
  • Work with other healthcare providers to ensure a smooth handoff and continuity of care after discharge. 

• Patient Education and Support:  

  • Provide education to patients about managing their condition, understanding new medications, and any lifestyle modifications necessary for recovery. 
  • Ensure patients understand the importance of attending follow-up appointments and adhering to their medication regimens to avoid readmissions. 

• Monitoring and Reporting:  

  • Track patient progress during the transitional care process, documenting key milestones and concerns. 
  • Communicate with the physician regarding any changes in the patient’s health or concerns identified during follow-up. 
  • Ensure that all documentation is complete, accurate, and entered into the EHR system in a timely manner. 

General Administrative Responsibilities 

• Record Keeping and Documentation: 
  • Maintain accurate and up-to-date patient records, including medication lists, refill history, and transitional care follow-ups. 
  • Ensure proper documentation in the EHR system, including follow-up communications, assessments, and care coordination efforts. 
• Collaboration with Healthcare Team: 

  • Work closely with the care team, including physicians, nurses, and office staff, to ensure that patient care is seamless and that all tasks related to medication management and transitional care are completed efficiently. 

• Compliance and Confidentiality: 

  • Ensure adherence to all relevant privacy regulations (e.g., HIPAA) and office policies regarding patient confidentiality and the handling of medical information. 

Qualifications

Qualifications: 

• Education: Licensed Practical Nurse (LPN) or Medical Assistant (MA) with relevant certification and/or experience in medication management or care coordination. 

• Experience:  

  • At least 2 years of experience in a medical office or healthcare setting, preferably with experience in medication refills, transitional care management, or patient coordination. 
  • Familiarity with electronic health records (EHR) systems and basic administrative tasks. 
  • Knowledge of medication management processes and transitional care practices. 

• Skills:  

  • Strong organizational and time-management skills. 
  • Excellent communication skills, both written and verbal, to interact effectively with patients, families, and healthcare providers. 
  • Ability to work independently and as part of a collaborative healthcare team. 
  • Attention to detail and ability to handle multiple tasks simultaneously. 
  • Compassionate, patient-focused approach to care. 

• Language: Written and spoken English required 

Physical Demands: Ability to sit, stand, and walk for extended periods. Occasional lifting and carrying of medical records or supplies.   

Work Environment: Office hours typically Monday through Friday, 8 hours per day. Fast-paced community health center setting, potential exposure to infectious diseases, interaction with diverse patient population. 

Benefits: Medical, Vision, and Dental coverage, 4% 401k Contribution, $50 a month HRA contribution to be used towards qualifying medical expenses, Paid Time Off (PTO) plus paid holidays. 

Equal Opportunity Employer: North Olympic Healthcare Network is an equal opportunity employer (EOE). All applicants will receive equal consideration for employment without regard to age, race, color, national origin or ancestry, ethnicity, family or marital status, sex (including gender, pregnancy, sexual orientation, and gender identity), genetic information, disability, creed, religion, citizenship, socio-economic status, military or veteran status, or any other characteristic protected under applicable federal, state, or local law. 

Salary : $20 - $26