Transition Of Care Coordinator II

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Transitions of Care Coordinator II (TOC Coordinator II) is an experienced non-clinical care coordinator responsible for managing complex transitions of care for Medicare Advantage members following inpatient admissions, emergency department visits, skilled nursing facility stays, and other qualifying transitions. The TOC Coordinator II independently coordinates post-discharge services, facilitates communication across the healthcare continuum, and addresses barriers to care to promote timely follow-up, member engagement, and successful transitions. In addition to direct care coordination responsibilities, the TOC Coordinator II serves as a resource to TOC Coordinator I staff by providing guidance on departmental workflows, supporting onboarding activities, promoting documentation quality, and participating in quality improvement initiatives. The TOC Coordinator II collaborates closely with Registered Nurses, Licensed Vocational Nurses, Social Workers, providers, and interdisciplinary teams while ensuring compliance with CMS, NCQA, organizational policies, and regulatory requirements.

Functions & Job Responsibilities

• Independently coordinate transitions of care activities for members with moderate to complex non-clinical care coordination needs.
• Conduct timely outreach to members and caregivers following qualifying transitions to facilitate post-discharge follow-up and continuity of care.
• Coordinate primary care, specialty care, behavioral health, home health, pharmacy, transportation, interpreter services, durable medical equipment, and other post-discharge services.
• Obtain and organize discharge summaries, medical records, provider documentation, and other clinical information necessary to support the interdisciplinary care team.
• Identify barriers to care including transportation, housing instability, food insecurity, financial concerns, language needs, caregiver support, and access to community resources.
• Coordinate referrals to internal Population Health programs including Transitions of Care, Complex Case Management, Disease Management, Behavioral Health, Social Work, and Community Resource programs.
• Collaborate with hospitals, physician offices, skilled nursing facilities, home health agencies, pharmacies, and community organizations to facilitate seamless care transitions.
• Monitor assigned members throughout the transition period to ensure follow-up services are completed and escalate unresolved issues as appropriate.
• Recognize situations requiring clinical intervention and promptly communicate concerns to the Registered Nurse or Licensed Vocational Nurse.
• Serve as a resource to TOC Coordinator I staff by providing guidance on workflows, documentation standards, work queues, and departmental procedures.
• Assist with onboarding, orientation, and day-to-day support of new coordinators.
• Participate in interdisciplinary care team meetings by providing updates on care coordination activities and outstanding member needs.
• Monitor assigned work queues to ensure timely completion of transition activities and regulatory timeframes.
• Maintain complete, accurate, and timely documentation in the care management platform in accordance with departmental standards.
• Support quality improvement initiatives, documentation audits, workflow enhancement projects, and corrective action plans.
• Identify opportunities to improve operational efficiency, member experience, and care coordination processes.
• Maintain confidentiality of protected health information in accordance with HIPAA and organizational policies.
• Maintain current knowledge of Medicare Advantage requirements, transitions of care workflows, and organizational policies.
• Participate in continuing education and departmental training activities.
• Perform other duties as assigned.