Transitional Care Coordinator, Praxis Health - Portland

Job Description:

Praxis Health is seeking a dedicated and compassionate Transitional Care Management (TCM) Coordinator to oversee and facilitate the transitional care process for patients moving between healthcare settings. The Transitional Care Coordinator is responsible for successfully managing transitions from an inpatient admission or emergency department to an outpatient setting by providing care coordination, necessary interventions, medication reconciliation/adherence, and ensure timely post discharge appointment with Primary Care Provider.

Monitors daily reports to identify patients in need of post discharge follow up care with the Primary Care office. In addition, may be asked to help support with key system wide initiatives by collaborating with the Quality department.

Compensation: Experienced candidates with job readiness will begin $25/hour

Check out this short video that shows why the Praxis Health family is so special. Please click here: https://youtu.be/MrNWtn42prY

• Medical, Dental, Vision with In-Network & Custom Network discounts
• 401(K) with discretionary employer match
• Paid Time Off
• Free clinical diagnostic laboratory testing performed in house

• Assists all patients through the healthcare system by acting as a patient advocate and navigator
• Communicates information to the patient’s primary care provider. Facilitates a follow up office appointment with the PCP within appropriate timeframe.
• Works collaboratively with providers, care management team, and Quality Department, to identify any barriers affecting timely patient care.
• Works collaboratively with the Quality department on key system wide metrics and initiatives.
• Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider
• Maintain timely and complete medical record documentation and billing of all encounters.
• Coordinates continuity of patient care with patients and families following hospital discharge and emergency room (ER) visits.
• Assists the multidisciplinary team in managing the high-risk patient, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Conducts screenings for patients and/or assists all support staff as needed.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management/reconciliation based upon standing orders and protocols.
• Evaluates clinical care, utilization of resources and development of new clinical tools, forms and procedures
• Adhere to the scope of practice for LPN or RN per state regulatory guidelines
• Effectively participate in various internal committees and performs other duties as requested by management.
• Maintain continuing education requirements as required for role.
• Facilitates and actively participates in programs with internal and external providers or payors.
• Maintains compliance with all policies and procedures
• Adheres to all confidentiality and HIPAA requirements as outlined within Policies and Procedures.
• Other duties as assigned

Minimum Qualifications:

• High school diploma or general education degree (GED).
• Licensed Practical Nursing (LPN) or Registered Nursing from an accredited institution, a community college program in nursing, or an accredited university.
• Basic Healthcare BLS certification.
• Knowledge of medical terminology and managed care.

• Minimum of two year of direct patient care experience in a clinical or hospital setting
• Minimum of three years’ experience in a healthcare, health plan or adjacent field.

• Motivational Interviewing
• Communicating with patients by telephone
• Proficient computer skills, including Microsoft Office (Word, Outlook, Teams and Excel)
• Experience in chronic disease management, case management, utilization management and adult acute care
• Previous EMR experience
• Knowledge of ICD and CPT coding

• Knowledge of organizational policies, regulations and procedures to administer patient care.
• Knowledge of medical equipment and instruments, common safety hazards, and precautions to establish a safe work environment.
• Self-disciplined, energetic, passionate, innovative A team player that can follow a system and protocol to achieve a common goal.
• Able to maintain confidentiality with all aspects of information in accordance with practice, state and Federal regulations Confidence to communicate and outreach to other community health care organizations and personnel.
• Ability to function independently within scope of practice.

About Us:

Praxis Health is a family of medical groups providing high quality healthcare throughout the state of Oregon. Our community-based clinics are the DNA of our business, providing better medicine, advocacy for our patients, and a satisfying and collaborative culture for our providers and staff.

The Praxis family approach is dynamically different than other healthcare companies in Oregon. We are not “big box” health care, but rather a company of small groups and clinics, of nimble micro-cultures that can quickly adapt to industry changes, as well as patient needs.

We have been serving communities across the beautiful and adventurous state of Oregon for over 50 years! And we are pioneers and thought leaders in the industry. Our commitment to innovative and operational excellence has allowed us to create healthcare solutions that are both cost-efficient and cutting edge.

Come see how healthcare is done right!

General Physical Requirements:

Physical Demands:

• Manual dexterity for office machine operation including computer and calculator; stooping, bending to handle files and supplies, or sitting for extended periods of time.
• Stress can be triggered by multiple staff demands and deadlines.

Work Environment:

Home office.

Equal Opportunity Statement:

EOE Disabled/Veteran

Praxis Health is an Equal Opportunity Employer and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.