• Job Description

  Req#: JN -052026-573233
  Job Title:
  
  Transition of Care / Discharge Coordinator - Ambulatory (Epic / UR)
  
  Hourly/Salary Compensation Range:
  
  18-20/hr
  
  Location:
  
  • 100% Remote
  • Supports Pacific Time Zone
  • Candidates must reside inMST or PSTtime zones
  
  Hours:
  
  • 7:30 AM - 3:30 PM PST
  • Rotational weekends(approximately every couple of weeks)
  • Holidays required
  
  Start Date:
  
  6/22/2026
  
  Job Description / Summary
  
  The Transition of Care / Discharge Coordinator coordinates and implements the Transition of Care (TOC) / Discharge (DC) plan for ambulatory patients. The role prioritizes and coordinates discharge planning through critical thinking, teamwork, and effective communication with providers, patients, families, and external vendors to support timely, safe discharge and appropriate post-discharge care.
  
  Management reserves the right to revise the job description or assign additional responsibilities based on operational needs.
  Key Job Accountabilities
  
  Collaboration with Care Coordination Team
  
  • Partner withCase Managers and Social Workersto:
    • Assess baseline patient needs
    • Identify post-hospital support requirements
  • Support development and execution of theTOC plan, including:
    • Communicating provider options and available resources
    • Clarifying expected discharge timelines
  • Ensure patients and facilities understandbenefit coverage; coordinate with payers as needed
  • Monitor progress toward TOC goals andescalate barriersto Case Managers and Social Workers
  • Keep patients and facilities informed of TOC plan progression
  • Coordinatepost-discharge referrals and authorizations
  • Communicate referral status and barriers throughout the day to support timely discharge
  • Facilitatepatient transfer to post-acute facilities, including:
    • Preparing documents
    • Obtaining physician signatures
    • Coordinating transportation
  
  Departmental Goals & Objectives
  
  • Round with Case Managers and Social Workers to provide updates and receive direction
  • DeliverMedicare \u201cImportant Message\u201d (IM)and educate patients/facilities on appeal rights
  • Proactively identify and escalatebarriers to discharge
  • Participate indaily huddles and department meetings
  • Contribute toteam prioritization and problem-solving
  • Collaborate on interdependent tasks and demonstrate flexibility
  • Share knowledge and fostercollaborative relationships
  
  Communication & Documentation
  
  • Maintain accurate and timely documentationper department standards
  • Enter Care Coordination notes in theEMR(Epic; Allscripts for closing discharge cases)
  • Document patient/facility preferences and key decisions
  • Enter final post-discharge provider information andclose discharge cases in Allscripts
  • Provide clerical support as needed (copying, faxing, scanning,data entry)
  • Complete required department reporting forms
  
  Customer Service
  
  • Demonstrate professionalism and respect in all interactions
  • Build positive relationships with internal and external partners
  • Resolve issues effectively and escalatequality/risk concernsas needed
  • Comply withHIPAAand confidentiality standards when transmitting patient information
  Skill Set Requirements
  
  • Required:
    • Epic EHR knowledge and experience
    • Experience withUR transmission
    • High-volume faxmanagement
    • High-volume voicemailmanagement
    • Data entry experience
    • Willingness to workrotational weekendsandholidays
    • Strong written and verbal communication skills
    • Effectiveinterpersonal and time management skills
    • Ability to work in afast-paced environmentwith shifting priorities
    • Ability to workindependently with minimal direction
    • Strongprioritization and discretion
    • Intermediate PC and word processing skills
  • Preferred/Nice to Have:
    • Experience withAllscripts
    • Prior work incare coordination, discharge planning, or case management supportin healthcare
    • Experience deliveringMedicare IMor similar regulatory notices
  Education / Certifications / Licenses
  
  • High School Diploma or equivalent experience required

• About the company

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