CareFirst Careers

Transition Care Coordinator

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Resp & Qualifications

PURPOSE: Transition Care Coordinator is assigned to those post-acute care facilities within a specific PCMH Region or to facilities outside of the MD, DC and Northern VA are to oversee the Transitions of Care Program, as follows:  

1. Supports the PCMH and other TCCI Programs for both attributed and non- attributed members, ensures the coordination and continuity of health care as Members transfer from the acute care setting to a post- care setting, or home.
2. Provides the critical bridge between acute inpatient care and post-acute settings for Members in need of intensive skilled or rehabilitation services.
3. Transitions Members to the appropriate TCCI Programs, including Attributed and Non-attributed LCCs, Home Based Services or Behavioral Health and Substance Use Disorder Programs to best address ongoing medical and behavioral health needs of the Member.
4. Through the timely and appropriate use of post-acute care, facilitates the Member’s return to pre-illness or pre-injury baseline.
5. Reduces preventable hospital ER visits and/or readmissions by improving care coordination in the post-acute care setting.

Under the general direction of the Director of Post-Acute Transitions of Care, the incumbent’s responsibilities include, but are not limited to, the following:

Rapidly assesses Members for post-acute care coordination needs

  • Conducts exceptional clinical assessments of Members physical and psychological needs
  • Rapidly triages Members to the appropriate post-acute facility based on the needs identified and the treatment plan. Determines the appropriate level of clinical care needed in the post-acute setting.
  • Identifies Members, with an emphasis on the Core Target population, who would benefit from participation in TCCI programs based on program guidelines, analytics and clinical judgment
  • Engages Members to participate in the TCCI programs and provide ongoing follow up assessments and care coordination
  • Provides member education to ensure understanding discharge plan of and knowledge of health care resources.
  • Collaborates with member/caregiver, and facility staff as necessary to close care gaps when identified.

Implements an effective Post-Acute Transitions of Care Program for attributed and non-attributed Members.

  • Engage identified attributed and non-attributed Members/Caregivers while Member is inpatient. 
  • Discusses and reviews the discharge plan, addresses Member/caregivers’ concerns.
  • Collaborates with the facility discharge planner, liaison, or Case Manager during the Member’s stay to discuss and review the discharge plan.
  • Contacts Members/Caregivers post discharge to assess for ongoing care coordination and to improve the care connections across the health care continuum. 
  • Actively follows up to verify the successful connection to other TCCI programs
  • Assist Members who do not have a primary care practitioner to select a PCP for care coordination and improved outcomes through the CareFirst website with an emphasis on PCMH PCPs
  • Proactively identifies, assesses, and coordinates necessary interventions such as Home-Based Services, Comprehensive Medication Review (CMR), Behavioral Health Services or other TCCI programs.

Communicates and interacts with Members, TCCI Care Coordinators, Physicians, and other providers.

  • Demonstrates proficiency and knowledgeable related to the TCCI Programs.
  • Improves communication between Members / Caregivers, PCPs and other providers to ensure appropriate care coordination
  • Maintains open communication with all providers and TCCI Care Coordinators 
  • Communicates weekly with the facility care team and Members/Caregivers for identified Core Target members.
  • Improves communication during transitions between providers, Members and caregivers to assure smooth transitions.
  • Provides timely and accurate communication and documentation of information between TCCI Care Coordinators, Providers, Members and Caregivers.

Manages all CareFirst Products

  • Follows NCQA Standards, CareFirst Medical Policy, Apollo Guidelines and Modified AEP to manage their member assignments
  • Understands all CareFirst lines of business to include Commercial, FEP, and Medicare secondary policies.
  • Follows member contracts to assist with benefit determination and care coordination within the members benefit structure

SUPERVISORY RESPONSIBILITY: This position does not have any direct reports.  The Transition Care Coordinator oversees the inpatient discharge planning process and coordinates the discharge plan with multiple healthcare professionals.

Requires a bachelor’s degree in Nursing or equivalent experience and must have 7-10 years of increasingly responsible hospital related experience working in Care Management, Discharge Coordination, Home Health, or Disease Management; must possess extensive knowledge of how to manage care delivery guidelines and systems.  Proven care management experience is critical.

The incumbent must have excellent analytical and problem-solving skills, excellent organizational, communication and coordination skills.  This position requires effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices.  The incumbent must be able to apply complex problem-solving abilities to achieve problem and process solutions. The incumbent must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. The incumbent must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. The incumbent must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

A current DC, MD, or VA Registered Nurse License is required.

*Required vaccinations/screenings and training requirements are subject to change based on Departmental policies.
**Assignments are subject to change based on evolving business needs

Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards relating to transitional care/case management.  Previous work experience within CareFirst Care Management.  Working knowledge of CareFirst IT and Medical Management systems.

MSN or CCM, and familiarity with web based software application environment.


  • The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.
  • Must be able to provide face to face contact with inpatient member at assigned hospital facility.
  • Must provide own transportation to assigned hospital facilities, and to attend onsite any required meetings, trainings, or other assigned functions, at designated CareFirst office.
  • Must be able to work in an office setting, primarily seated while performing duties for a minimum of 8 hours per work day.
  • Walking and standing is required.  Lift weight up to 25 pounds on occasion.
  • Hands are regularly used to write, type, key and handle or feel small controls and objects.  Must be able to type and to speak on the telephone simultaneously.
  • The employee must have good visual acuity for computer viewing and must frequently talk and hear. 



Department: Hospital Transition of Care

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 5/18/2018

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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