Transition of Care Coordinator

Job Description

About Total Care Connect

Total Care Connect (TCC) is a mobile integrated health organization delivering in-home clinical and preventive care to members across Ohio and surrounding regions. We support health plans, health systems, and value-based organizations by reaching members where they are — in their homes and communities — to improve access, close care gaps, and reduce avoidable utilization.

As a tech-enabled, field-based care delivery organization, our teams provide a range of services including preventive care, chronic condition support, transition-of-care visits, member engagement, and navigation. We operate with a focus on high-quality member experience, operational excellence, and coordinated care across clinical, administrative, and remote teams.

Position Summary

The Transition of Care Coordinator (Clinical) is responsible for reviewing daily hospital discharge notifications (ADT feeds), triaging member needs, and coordinating timely post-discharge in-home or telehealth visits. This role serves as the clinical support layer for TCC’s Engagement and Care Coordination teams and plays a critical part in ensuring a safe transition for members returning home after hospitalization.

Compensation

Salary $60,000 – $65,000, commensurate with experience.

Key Responsibilities

Clinical Triage

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

Member Engagement & Coordination

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.

Communication & Partner Support

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.

Program Support & Workflow Development

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.

Qualifications

Required (one of the following):

Licensed Practical Nurse (LPN), or

Medical Assistant (MA) with strong post-acute or hospital experience, or

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.

Why This Role Matters

This role ensures members have a safe, supported transition from hospital to home and enables TCC to deliver timely post-acute care. The Coordinator directly impacts readmission reduction, quality outcomes, and care continuity for our health plan and provider partners.

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Full-time

Fully remote