<p><strong>Job Title:</strong> Transitions of Care (TOC) Coordinator</p><p><strong>Location:</strong> Remote (<strong>Must reside in New York State</strong>)</p><p><strong>Employment Type:</strong> Part-Time (Weekends: Saturday & Sunday, 9:00 AM – 5:00 PM EST)</p><p><br></p><p><strong>About the Role</strong></p><p>We are seeking a detail-oriented, remote <strong>Transitions of Care Coordinator</strong> based in New York State to support weekend operations. In this role, you will play a critical part in tracking member admissions and discharges across care settings, communicating status updates, scheduling post-discharge appointments, and collaborating with interdisciplinary care teams to facilitate smooth transitions back to the community.</p><p><br></p><p><strong>Key Responsibilities</strong></p><ul><li><strong>Admission & Discharge Monitoring:</strong> Reconcile daily Regional Health Information Organization (RHIO) alerts to identify Emergency Department, Observation, Inpatient, Skilled Nursing Facility (SNF), Behavioral Health, and Rehabilitation admissions and discharges.</li><li><strong>Notification & Communication:</strong> Distribute daily admission/discharge notifications to the Transitions of Care (TOC) Team and Utilization Management; monitor status changes throughout the day and communicate significant updates.</li><li><strong>Facility Outreach:</strong> Contact hospitals, SNFs, rehab centers, and other care facilities to obtain member status updates, anticipated discharge dates, discharge readiness, and disposition details.</li><li><strong>Clinical & Team Collaboration:</strong> Notify assigned TOC RNs of status changes, clinical updates requiring intervention, and discharge barriers; coordinate communication across facilities, providers, TOC Nurses, Care Managers, and Utilization Management.</li><li><strong>Appointment Scheduling:</strong> Schedule timely post-discharge appointments with Primary Care Providers (PCPs) and specialists as requested to support continuity of care.</li><li><strong>Barrier Removal & Care Support:</strong> Help identify and resolve barriers that may delay discharge or impact a successful transition back to the community, ensuring appropriate follow-up services are coordinated.</li><li><strong>System Documentation:</strong> Create, update, and close Service Interruptions (SI) for Emergency Department, Observation, Inpatient, SNF, Behavioral Health, and Rehabilitation stays.</li></ul><p><strong>Schedule & Location Requirements</strong></p><ul><li><strong>Work Schedule:</strong> Part-Time, Weekends Only (Saturday and Sunday, 9:00 AM – 5:00 PM EST).</li><li><strong>Residency Requirement:</strong> Candidates <strong>must currently reside in New York State</strong>.</li><li><strong>Work Environment:</strong> 100% Remote.</li></ul><p><br></p>
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