TOC Care Management Coordinator

Admission & Discharge Management Reconcile RHIO and Hamaspik Central alerts daily to identify Emergency Department, Observation, Inpatient, Skilled Nursing Facility (SNF), Behavioral Health, and Rehabilitation admissions and discharges. Distribute daily admission and discharge notifications to the Medicare TOC Team and Utilization Management. Monitor admissions and discharges throughout the day and communicate significant updates to the TOC team. Care Coordination Contact hospitals, Skilled Nursing Facilities (SNFs), rehabilitation centers, and other facilities to obtain member status updates. Monitor anticipated discharge dates and communicate discharge readiness to the assigned TOC RN. Notify the TOC RN of changes in member status, barriers to discharge, and important clinical updates requiring intervention. Coordinate with facility staff to obtain discharge plans and discharge disposition. Schedule timely post-discharge appointments with Primary Care Providers (PCPs). Schedule specialty appointments as requested to support continuity of care. Coordinate communication between facilities, providers, TOC Nurses, Care Managers, Utilization Management, and other interdisciplinary team members. Assist in removing barriers that may delay discharge or impact a successful transition back to the community. Support continuity of care by ensuring appropriate follow-up services are coordinated after discharge. Guiding Care Documentation Create, update, and close Service Interruptions (SI) for Emergency Department, Observation, Inpatient, SNF, Behavioral Health, and Rehabilitation stays. Complete MAP and DSNP Hospitalization/SNF/Behavioral Health Admission Notification scripts accurately and within required timeframes. Verify facility information using NPPES and authorization records. Maintain complete, accurate, and timely documentation within Guiding Care. Provider Notifications Prepare and fax Notifications of Admission (NOA), Transfers, and Discharges to Primary Care Providers within required timeframes. Upload notifications and fax confirmations into Guiding Care. Obtain missing PCP contact information when necessary. Ensure discharge summaries and supporting documentation are forwarded to PCPs in accordance with HEDIS Transitions of Care requirements. Discharge Summary Coordination Request and obtain discharge summaries from hospitals and facilities. Perform ongoing follow-up until discharge summaries are received. Review discharge summaries to ensure required HEDIS Transitions of Care elements are present. Coordinate with TOC Nurses and Utilization Management regarding missing or incomplete discharge documentation. Ensure discharge documentation is distributed timely to PCPs. Internal Workflow Coordination Generate and assign activities for interruption of services during inpatient admissions. Generate notification of change in member status activities to assigned Care Managers. Generate resumption of services activities following member discharge. Coordinate with Authorization, DME, Home Care, Transportation, Vendor Management, and other internal departments to ensure services are suspended and resumed appropriately. Quality & Compliance Maintain and update the HEDIS Transitions of Care (TRC) tracker accurately and in real time. Ensure all TRC components, including Notifications of Admission, Notifications of Discharge, PCP notifications, discharge summaries, and supporting documentation, are entered completely and accurately. Monitor TRC compliance timelines to ensure all required activities are completed within established regulatory and organizational timeframes. Review the tracker daily for completeness, identify outstanding items, and follow up to resolve missing documentation or overdue tasks. Collaborate with TOC Nurses, Care Managers, Utilization Management, and other departments to obtain information needed to maintain an accurate and compliant TRC tracker. Support HEDIS, CMS Star Ratings, and internal quality initiatives by ensuring the accuracy, timeliness, and integrity of all TRC data and documentation. Identify discrepancies, trends, or potential compliance risks and escalate issues to leadership promptly. Participate in quality audits and process improvement initiatives to enhance the accuracy and efficiency of the Transitions of Care program. Required Skills Excellent organizational and time management skills. Strong communication and interpersonal skills. Ability to manage multiple priorities in a fast-paced environment. Strong attention to detail and documentation accuracy. Knowledge of Medicare Advantage, DSNP, and Managed Long-Term Care workflows. Experience with RHIO, Guiding Care, Hamaspik Central, and electronic medical records. Ability to work collaboratively with interdisciplinary teams, providers, hospitals, and community partners. Working knowledge of Excel and Word. Benefits: Medical, dental, and vision insurance Generous PTO package Multiple floating holidays 401 (K) with employer contribution