CareFirst Careers

Hospital Transition Coordinator, RN (Inova Fairfax Medical Campus)

Resp & Qualifications

PURPOSE: The Onsite/Dedicated Hospital Transitions Coordinator (HTC) is assigned to a specific hospital or facility (Inova Fairfax Medical Campus) within their Region to which they are familiar and oversees the Total Cost and Care Improvement (TCCI) Program, as follows:  
1. Supports the TCCI Program for all hospitalized CareFirst members, ensures the coordination and continuity of health care as patients transfer between different locations or levels of care
2. Accountable for improving coordination between patients, providers and caregivers through communication and follow up
3. Provides rapid triage to the appropriate Care Management Programs, including Complex Care Management through the Primary Care Medical Home (PCMH), Wellness, Disease Management, Home Based Services, and Comprehensive Medication Review to best address ongoing health needs of the member.
4. Ensure Members have a Primary Care Provider (PCP) and are scheduled for a post-discharge appointment before the Member is discharged from the hospital.
5. Conduct a clinical assessment of the Member and determine if the Member has ongoing care needs. Document findings as the Assessment Outcome.
6. Performs concurrent review for CareFirst members in accordance with the length stay guidelines outlined for the TCCI Program.
7. Consults with the Medical Director for medical necessity determinations and appropriateness of care.

PRINCIPAL ACCOUNTABILITIES:  Under the general direction of the Director of Regional Care, the incumbent’s accountabilities include, but are not limited to, the following:

Rapidly triages members into the appropriate levels for the TCCI program.

  • Understands the TCCI concept and protocols, and can advocate for the member.
  • Contemporaneously, identifies members for program participation based on program guidelines, analytics and using clinical judgment.
  • Engages members to participate in the TCCI program and establishes relationship and follow up plan for ongoing coordination and assessment
  • Assures member understanding of adequate support upon transition and knowledge of who to call if problem arise. Collaborates with facility staff as necessary to close gaps when identified.

Implements an effective TCCI program for members identified as Level 1.

  • Works with the hospital Admitting Office, Emergency Department, Registration and with CareFirst’s iCentric Portal to identify CareFirst Members who have been admitted
  • Meets with identified members daily while hospitalized.  Discusses and reviews the discharge plan, addresses member concerns, and proactively anticipates member needs at hospital discharge.
  • Contacts hospital discharge planner, liaison, or Local Care Coordinator during the triaged member’s hospitalization. Discusses and reviews the discharge plan.
  • Contacts identified CareFirst members post discharge and actively follow up to verify the transition plan and care connections.
  • Coordinates necessary interventions.
  • Communicates with the PCMH when members are attributed, to improve the care connections from another level of care. Offers assistance to those members who do not have a primary care practitioner to select a PCP for care coordination and improved outcomes through the CareFirst website.
  • Primary role as coordinator/facilitator—proactively guiding members to the appropriate CareFirst programs and resources designated as best, to achieve program goals of reduced readmissions, cost-efficiency and quality outcomes. 
  • Ensures the transition of care from one setting to another for identified CareFirst members.  Provides member centric interventions such as verifying appointments and coordinating medically necessary home health services.
  • Proactively identifies, assesses, and coordinates health care services based on the member’s needs and benefits.
  • Coordinates appropriate referrals for Care Management Programs.
  • Offers assistance to members and providers for alternative settings of care.

Communicates and interacts professionally with physicians, other providers, and members.

  • Builds and maintains a solid professional relationship with all of the targeted facilities (especially with hospitalists and Emergency Department physicians) and is proficient and knowledgeable about the Care Transition model. Communicates regularly with the Plan on the operational issues/concerns and barriers.
  • Improves communication during transitions between providers, members and caregivers to assure smooth transitions.
  • Provide timely and accurate communication of information as members move from one level of care to another.

SUPERVISORY RESPONSIBILITY: Oversees the hospital 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.  The incumbent must have 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 is required to have had the vaccinations listed below and been appropriately screened (and cleared) for the items listed below.  If the incumbent has not had them or been screened and cleared, they must do so upon acceptance of offer:

  • TB screening (and repeat annually)
  • MMR-V Immunity
  • Influenza Vaccine (Seasonal)

The incumbent is required to complete the following training as assigned by Management, including, but not limited to:

  • Infection control basics
  • TB Awareness
  • Bloodborne Pathogens (and repeat annually)

** Onsite Hospital Assignments are subject to change based on evolving business needs
A current DC, MD, or VA Registered Nurse License is required.

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.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   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.


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


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: 12/20/2018

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 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 facility, and to attend onsite any required meetings, trainings, or other assigned functions, at designated CareFirst office.
  • 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.
  • Must have the ability to communicate verbally effectively. Auditory ability to actively listen.

Potential Job Hazards:

The position is located within an inpatient hospital facility. 

  • Incumbents are required to state their purpose upon arrival to the member’s room so there is no confusion as to their role vs. the role of the direct care hospital staff. 
  • Incumbents do not provide any form of direct patient care.

Airborne Exposure:
There is the potential for exposure to airborne illnesses, such as, but not limited to, tuberculosis, measles, mumps, rubella, varicella and influenza.  The following administrative controls are in place to limit or minimize exposure potential:

  • Incumbents do not enter any inpatient rooms, or hospital rooms designated with Respiratory precautions, or where any procedures are being done that produce respiratory droplets.
  • Incumbents are required to remain at least 3 feet away from the inpatient member at all times.

Bloodborne Pathogens:
There is the potential for exposure to Bloodborne Pathogens if not aware of surroundings at all times.  The following administrative controls are in place to limit or minimize exposure potential:

  • Incumbents do not touch patients;
  • Incumbents must practice Universal Precautions at all times.

Sponsorship in US

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

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