Total Care Connect · 1 month ago
Transition of Care Coordinator
Columbus, OH
Full-time
Onsite
Entry, Mid Level
$60K/yr - $65K/yrTotal Care Connect (TCC) is a mobile integrated health organization delivering in-home clinical and preventive care to members across Ohio and surrounding regions. The Transition of Care Coordinator is responsible for reviewing hospital discharge notifications, triaging member needs, and coordinating timely post-discharge visits to ensure safe transitions for members returning home after hospitalization.
Hospital & Health Care
Responsibilities
Review daily ADT/discharge alerts to identify eligible members
Assess discharge diagnoses, risk level, and clinical appropriateness for TCC services
Prioritize outreach based on clinical needs and post-acute risk factors
Determine the appropriate intervention pathway
Conduct initial outreach to recently discharged members
Confirm discharge details, evaluate immediate needs, and assess potential barriers to care
Coordinate with the Care Coordination team to ensure visits are scheduled within required timeframes (24–72 hours)
Support members with education, planning, and navigation during early post-discharge periods
Serve as a clinical liaison to health plan case managers, hospital teams, and discharge planners
Provide status updates and close-loop communication back to referral partners
Ensure accurate documentation in TCC’s care platform and maintain program compliance
Assist in building and improving TOC workflows, SOPs, and process standards
Monitor TOC metrics including engagement rates, timeliness of visits, and readmission risk indicators
Collaborate across internal teams to improve operational effectiveness
Qualification
Required
Licensed Practical Nurse (LPN)
Medical Assistant (MA) with strong post-acute or hospital experience
Experience in Case Management
Preferred
Experience reviewing ADT feeds or discharge summaries
Familiarity with Medicaid and DSNP populations
Experience in home-based care, case management, community paramedicine, or value-based care
Strong communication and documentation skills
Company
Total Care Connect
Total Care Connect provides mobile healthcare that goes beyond the walls of the traditional healthcare environment and focuses within the walls of the patient’s home.
Founded in 2023Columbus, Ohio, US
11-50 employeesFunding
Current Stage
Early StageCompany data provided by crunchbase