Transitional Care Coordination Specialist

2 weeks ago


Indianapolis, Indiana, United States CINQCARE Full time
Job Overview

CINQCARE is dedicated to enhancing the delivery of healthcare services, particularly for underserved communities.

Position Summary

As a vital member of our team, you will oversee the Transitional Care Management (TCM) program. Collaborating with a diverse group of professionals, you will play a key role in the creation, execution, and continuous improvement of transitional care strategies.

  • Qualifications:
    • Completion of a Medical Assistant (MA) program.
    • Certification as a Medical Assistant or eligibility for certification.
  • Skills:
    • Proficient in basic computer applications, including Excel.
    • Experience with Electronic Health Records (EHR) is advantageous.
  • Communication Skills: Exceptional verbal and written communication abilities; capable of clearly presenting ideas and concepts to various stakeholders, including team members and partners. Proficiency in Microsoft Office Suite is required.
  • Relationship Management: Ability to cultivate and maintain effective relationships with business leaders and external partners.
  • Company Culture: Demonstrates sound judgment, strong ethical standards, and a collaborative spirit; motivated to thrive in a dynamic and entrepreneurial environment.
  • Innovative Mindset: CINQCARE is committed to addressing longstanding disparities in healthcare delivery. This role is essential in ensuring that our organization effectively fulfills its mission.

Key Responsibilities

  • Identify patients recently admitted to inpatient or skilled nursing facilities to facilitate TCM.
  • Monitor admissions and collaborate with hospital and skilled nursing facility personnel to support discharge planning.
  • Maintain tracking systems and update patient records with relevant status changes.
  • Engage with patients post-discharge to assist in scheduling their TCM visits and ensure adherence to visit timelines.
  • Conduct follow-up calls after discharge to evaluate patient needs and address any gaps in care.
  • Assist in locating skilled nursing facility placements to minimize unnecessary emergency room visits and hospitalizations when suitable.
  • Streamline the transition from hospital discharge to skilled nursing facility rehabilitation by coordinating with partners to expedite admissions.
  • Ensure patients have the necessary medications, care instructions, and durable medical equipment upon returning home.

Work Environment

This role involves both in-home and office-based responsibilities. Office work is conducted in a standard office environment with controlled air and artificial lighting.

Effective communication with customers, vendors, management, and colleagues is essential, often requiring interaction with individuals who may be distressed. Regular use of telecommunication and email is necessary. The position may involve extended periods of sitting and occasional lifting of up to 30 lbs. Proficiency in using standard office equipment, such as computers and copiers, is required.



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