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Transition of Care Coordinator
Chicago, IL

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Posted 4/18/2017

Required Skills

  • Licensed Registered Nurse required, BSN preferred
  • Transition of Care / Case Management certification or obtain within 2 years  (e.g. CCM, RN-BC,CMCN)
  • Knowledge of Medicaid and Medicare coverage preferred
  • 2 – 4 years utilization review and / or managed care experience required
  • Knowledge of medical problems encountered in the Medicare, ICP and FHP / ACA population
  • Strong computer skills – Microsoft Office Suite
  • Car and valid Driver’s License
  • Strong communication and interpersonal skills
  • Ability to effectively present medical information one-on-one and to small groups
  • Experience in the application of InterQual criteria or other evidence-based medical criteria

Job Description

  • Oversees the utilization review activities and transitional care duties on a daily basis
  • Assesses the member’s clinical need against established guidelines and / or standards to ensure that the level of care and length of stay are medically appropriate
  • Interacts and works closely with hospitals and delegated medical groups UM departments
  • Reviews and provides oversight and intervention with discharge planning needs
  • Ensures coordination and continuity of health care for enrollees as they transfer between locations or different levels of care
  • Notifies Primary Care Physicians with out of network admissions
  • Works closely with social workers in transitional care planning resources
  • Documents enrollee utilization and transitional care in the health plan system
  • Coordinates arrangements to meet the needs of enrollees when they are discharged home which involves assisting with referrals and special arrangements for services and supplies
  • Interacts and communicates with interdisciplinary care teams striving for continuity and efficiency as the member is managed along the continuum of care
  • Assists enrollees with access to service, educational programs and understanding of medical issues
  • Participates in QM / UM Committee meetings as required
  • Manages the Continuity of Care (e.g. prospective enrollees request for continuity of care, enrollees in the third trimester of pregnancy and ongoing course of treatment enrollees)
  • Performs other duties as assigned

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