Care Transition Coordinator II – 25-187 role at Hill Physicians Medical Group
Overview
Hill Physicians Medical Group is shaping the future of healthcare with actively managed care that prevents disease, supports those with chronic conditions, and anticipates member needs. We are recognized as a “Best Place to Work” and a “Healthiest Place to Work” in the Bay Area.
Job Responsibilities
Facilitates pre and post‑acute care to avoid readmissions and ER visits.
Serves as liaison between hospital clinicians, providers, vendors, nursing facilities, and HPMG Care Management staff.
Processes authorizations for discharge needs.
Schedules PCP and specialist appointments.
Coordinates care at bedside and PCP offices and refers patients to appropriate Case Management staff.
Monitors and tracks issues to ensure timely resolution and communicates feedback to referral sources.
Inpatient
Completes intake process – facesheet receipt, verifies eligibility, and builds referral into authorization.
Verifies benefit details with health plans.
Calculates LACE score at admission and documents in the authorization.
Assists nursing staff in obtaining clinical information and summarizes for continuing nursing facility stays.
Receives and processes authorizations needed for timely discharge.
Engages patient and caregivers upon admission, discharge instructions, transition preparedness, and follow‑up appointments within 7 days of discharge.
Shares treatment/discharge plan with member and communicates for transition to next level of care.
Participates in physician/case management/concurrent review rounds as needed.
Completes ad hoc health plan drilldown requests.
Travels to hospitals in assigned regions up to 100% of the time.
Maintains client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory, and accreditation standards.
Performs other duties as assigned.
Welcome Home
Receives in‑basket notification of discharge, calculates LACE score, and routes case to appropriate team member.
Uploads discharge summaries, medication list, and other documentation to the Welcome Home episode in Epic.
Completes initial Welcome Home call to member within 36 hours and refers high‑risk cases to Welcome Home nurse.
Follows up and addresses any needs identified during outreach call.
Sends letters externally as appropriate.
Collaborates with interdisciplinary team via telephonic outreaches to support implementation of the identified discharge plan.
Makes PCP follow‑up appointment within 7 days of discharge.
Completes ad hoc health plan drilldown requests.
Travels to PCP offices at minimum once per quarter or as needed.
Maintains client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory, and accreditation standards.
Performs other duties as assigned.
Case Management
Creates episode for referral to Case Management.
Runs LOH report, creates episode, and refers case to health plan, Case Manager, or Social Worker.
Outreaches to members for non‑complex needs and updates chart notes.
Offers education to member about Case Management services.
Refers appropriate cases to designated staff.
Enter transition notes upon referral to designated staff.
Makes PCP follow‑up appointment within 7 days of discharge as applicable.
Completes ad hoc health plan drilldown requests.
Travels to PCP offices at minimum once per quarter or as needed.
Maintains client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory, and accreditation standards.
Performs other duties as assigned.
Required Experience
3‑5 years of related managed care experience.
Working knowledge of medical terminology.
Ability to coordinate effectively with members, providers, hospital and office staff, health plans, internal departments, community resources, and peers.
Ability to work independently as well as in a team environment.
Multi‑tasking, ability to prioritize, and strong critical thinking skills.
Excellent organizational and communication skills and ability to meet timeframes.
Computer proficiency with Microsoft Word, Excel, EHR, and web‑based applications.
Experience with CPT/ICD and codes preferred.
Required Education
High school diploma or GED.
Additional Information
Salary: $30 – $33 Hourly.
Equal Opportunity Employer
Hill Physicians is an Equal Opportunity Employer. We welcome all who are curious, energetic, and eager to lead the next generation of managed care.