Resp & Qualifications
The Transitional Care Coordinator is supporting the CareFirst Maryland Medicaid Program
Position Summary: The Transitional Care Coordinator (TCC) is responsible for proactively care coordinating and assisting with transitioning medically complex members from the inpatient setting to home. The TCC works collaboratively with various representatives of the multidisciplinary care team in the hospital, home, and ambulatory care setting. The TCC performs assessments on members to evaluate and identify risks/barriers that may impact adherence to medical treatment plans. The TCC assists the member and the member’s families with understanding discharge instructions and assisting with care coordination needs post discharge to ensure safe transitions of care.
Essential Duties and Responsibilities:
- Conducts Post Discharge Assessments on medically complex members to determine barriers to self-care
- Collaborates with member’s family and healthcare team to provide a discharge process that enhances patient satisfaction, efficiency of time and resources, and improved post-discharge outcomes
- Collaborates effectively with the member and family to establish an individualized and successful plan of care for each member, with an emphasis on appropriate services to meet health needs
- Communicates with community practice care managers and appropriately transitions members to practice care manager, or if not applicable follows member for 30 days post discharge
- Monitors member compliance telephonically and is available to provide advice per protocols
- Serves as a resource and educator to the member and his/her family
- Provides referrals into ongoing case management programs as needed
- Monitors member status against appropriate outcomes and addresses clinical issues with the care team.
- Documents member self-management measures, mutually agreed upon interventions, and progress or barriers
- Intervenes on behalf of the member and organization to reduce avoidable emergency room visits or unnecessary hospital admissions
- Functions as a major contributor as it relates to readmission reduction strategies.
- Documents all activities in the appropriate system(s) on a timely basis
- Monitors and facilitates appropriate utilization of resources using evidenced-based clinical criteria.
- Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options
- Participates in a regular rotation of after hours on call
- Other duties as requested or assigned
Education, Experience and Qualifications:
- A current Maryland nursing license without restrictions required
- 3-5 years of healthcare experience (preferably in case management or hospital/acute care) or similar experience reviewing patient medical care and services in one or more of the following specialty fields:
- High risk diseases and comorbidities (e.g. diabetes, hypertension, COPD, CHF, asthma)
- Complex Medical Illnesses (e.g. HIV/AIDS, ESRD, Oncology)
- Palliative Care/Hospice
- In-depth knowledge of current standards of medical practice and insurance benefit structures to facilitate medical review decisions and interpret contract benefits and managed care guidelines preferred
- Detailed knowledge and competency in all types of medical necessity decisions, including inpatient care, subacute/skilled care, outpatient care, hospice care, and home health care
- Health Plan experience is a plus
Knowledge, Skills and Abilities:
- Exceptional communication skills, both written and oral, with the ability to positively influence others with respect and compassion; fluency in a foreign language is a plus
- Strong work ethic built on a foundation of proactivity and teamwork
- Ability to navigate ambiguity with the aid of structured problem-solving techniques
- Committed to the practice of inquiry and listening
- Personal and professional track record that demonstrates a commitment to quality in health care
- A positive attitude: ability to work hard and operate efficiently in a fast-paced work environment and in a highly complex and dynamic movement for health delivery reform
- Substantial knowledge of Microsoft Office including SharePoint, Outlook, Excel, Word, and PowerPoint
- Proficiency in medical management software utilized for utilization review, medical appeals, and case management preferred.
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: www.carefirst.com/careers
Please apply before: 12/16/2020
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