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AlohaCare · 3 weeks ago

Transition of Care (TOC) Care Coordinator, Clinician RN or SW

Honolulu, HI

Full-time

Onsite

Entry Level

$61K/yr - $83K/yr

1+ years exp

AlohaCare is a local, non-profit health plan serving Hawai`i’s low-income residents. The Transition of Care (TOC) Care Coordinator, Clinician is responsible for conducting assessments and coordinating care for members transitioning from hospital to home, ensuring they receive necessary follow-up and support.

Health CareHealth DiagnosticsHospitalMedical

Responsibilities

Conduct a face to face and/or telephonic TOC assessment on complex care members prior to member being discharged from the hospital (Oahu) and post hospitalization. A TOC assessment will be completed with members who have complex admissions, readmissions, and/or have the potential of becoming high risk and complex, to include frequent Emergency Department utilization. TOC care collaboration with neighbor island members upon discharge from the hospital is achieved telephonically

Interacts with members, family, provider(s) utilizing clinical and social knowledge and expertise to determine the member’s current status and capacity to assess the options for service delivery

Assist member with scheduling the PCP and/or Specialist post discharge follow-up appointments, transportation, and DME needs post hospitalization

Provides individual member education on preventative health care measures and on medication education and compliance

Upon member discharge, ensure PCP/Specialist has current member information to include the discharge instruction, discharge summary, current medication list ~~or~~ and other information requested

Conduct a follow-up phone call with member and/or caregiver post discharge, conduct an appointment reminder call after the scheduled PCP/ Specialist follow-up appointment, and as needed throughout the TOC 30 Day Program

Assist member with outreach to Community Health Centers, primary care provider BH/SUD, and/or Specialist as needed

If necessary, refer members to Health Coordination, Behavioral Health Peers Supports, Disease management, Care Navigators, Community Health Workers and Pharmacy departments when additional assistance is required

Maintains accurate and up to date written documentation and records of TOC activities in information system (Guiding Care/G8) according to appropriate TOC and/or clinical guidelines

Ensures compliance with all state and federal regulations, including HIPAA standards of confidentially protected health information, reporting of critical incidents and reporting of quality-of-care issues

Participate in TOC Care Coordination staff meetings, interdisciplinary care team meetings, trainings, in-services, and Daily Inpatient Rounds as required

All other duties assigned

Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures

Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, state and federal laws, and rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title

Qualification

Licensed RNLSWClinical assessmentsBehavioral health case managementManaged care experienceTransition of care activitiesLocal resourcesCustomer service skillsMicrosoft Office skillsFirst AidCPR CertificationInterpersonal skillsProblem-solving skillsTime management

Required

Associate's degree in health care administration, Nursing, Social Work, Long Term Services and Supports, Public Health, Behavioral Health, or related field or equivalent combination of education and experience

Licensed RN, LPN, LSW, LMHC or LCSW in the State of Hawaii

Minimum of 1 year of related work experience in a clinical setting and/or in a managed care environment, experience with behavioral health case management, health plan experience, or other related work experience

Experience with performing post-inpatient transition of care activities

Ability to network with other providers for successful transition from inpatient to community-based services

Prior experience in clinical assessments, discharge planning, and utilization management

Ability to work with varied teams/professionals for inter-disciplinary case consultation and discharge planning

Knowledge of local resources, providers, and referral processes

Support AlohaCare's corporate core values in all interactions

Achieves results, builds trust, communicate effectively, customer and quality focused

Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization

Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations

Professional telephonic etiquette skills

Ability to solve problems, analyze, think critically, and make good judgment

Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills

Able to work independently with minimal supervision

Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment

Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure

Intermediate skills in Microsoft Programs: Word, Excel or Access Databases, Outlook and PowerPoint Experience in the operation of general office equipment to include PC, fax/copy machine and phone system

Possession of valid driver's license with access to a reliable automobile

TB Clearance

First Aid and CPR Certification

Preferred

Experience with QUEST and Medicare programs and working knowledge of managed health care field

Minimum of 1 year of related work experience, health plan experience, experience in a clinical setting and/or in a managed care environment

Experience with individuals who are low-income or have special health care needs, including: HIV/AIDS, developmental disabilities, medical -fragile, older adults, and individuals with physical disabilities

Knowledge of local resources, providers, and referral processes