Transitional Care Coordinator (TCC)

Maxim Healthcare Services - Dover, DE3.6

30+ days ago
Maxim Healthcare Services is seeking a RN Case Manager for a direct placement with naviHealth as a Transitional Care Coordinator (TSC). As a naviHealth Care Coordinator, you will be responsible for identifying the appropriate Post-Acute Care (PAC) setting and evaluating a defined population for transitional needs post-discharge to improve outcomes. You will utilize our nH Predict functional assessment tool as a guide to support efficiency and best outcome.

Primary Responsibilities
  • This role is performed onsite at facilities or telephonically as directed by the manager.
  • Services are provided in a collaborative process that assesses, plans, implements, coordinates, monitors and
evaluates options and services required to meet the patient’s post-acute health needs, using communication and
available resources to promote quality, cost-effective outcomes.
  • May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC
management workflow system and functionally-based assessment technology tools. Provides outcome targets to
appropriate audience.
  • Utilizes naviHealth proprietary technology and industry standard evidence-based tools for consideration of appropriate
level of care, readmission risk and needed interventions.
  • Maintains nH Coordinate case documentation per established standards.
  • Collaborates effectively with the patient’s interdisciplinary health care team to coordinate an optimal transition plan to
the most appropriate PAC setting. The health care team includes physicians, health plan UM/CM Nurse, hospital
discharge planners, referral coordinators, etc. The patient and caregiver are involved in the decision making process
to minimize service fragmentation during care transition.
  • Provides telephonic post-discharge support to assist the defined population of patients in meeting short and long-term
goals with regards to their overall well-being. The TCC may collaborate with other care team members such as home
health providers to avoid redundant telephonic follow up and coordinate care.
  • The TCC partners with acute and post-acute interdisciplinary care team members to support discharge planning,
resolve barriers and to connect the patient to community resources and additional services.
  • Assess and monitors patient’s appropriateness for care setting (as indicated) according to nH Predict™, InterQual
criteria and/or industry standard evidence-based criteria. Communicates with Hospital Case management and
physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as
  • Utilizes knowledge of behavioral change science and principles to guide patient/caregiver interventions.
  • Addresses end of life issues including hospice and palliative care options.
  • Practices cultural competency with awareness and respect for diversity.
  • Facilitates the development of a culturally sensitive individualized transitional care plan for services that including
clinical, psycho-social, and environmental needs. Monitors and evaluates the effectiveness of the plan. Makes
recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated.
  • Provides individualized evidence based condition specific patient education directed at self-care and reduction of
exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.
  • Coordinates comprehensive post discharge health care services, support programs, and referrals for communitybased
  • Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for
process improvement.
  • Participates in weekly readmission and other type rounds as needed based upon opportunities.
  • Adheres to organizational and departmental policies and procedures.
  • Maintains confidentiality of all PHI information in compliance with HIPPA, federal and state regulations and laws.
  • Keeps current on federal and state regulatory policies related to utilization management and care coordination
(CMS guidelines, Health Plan policies and benefits)
  • Pursue multi-state licensure to meet business needs
  • Adheres to organizational departmental policies and procedures
  • Adheres to all local, state and federal regulatory policies and procedures
  • Must promote a positive attitude and work environment
  • Attends naviHealth meetings as requested
  • Performs all other duties as assigned
  • Holds as confidential the patient’s protected health information as required by applicable laws, regulations, or
agency/institution procedures.

  • Registered Nurse with current, active unrestricted licensure required
  • Current active unrestricted clinical license required
  • 5 years of clinical experience.
  • Case Management experience with CCM preferred.
  • Patient education background, rehabilitation, SNF and/or home
health nursing experience a plus.
  • Experience working with geriatric population preferred.
  • Excellent documentation and technology skills required
  • Self-starter with the ability to prioritize daily work load.
  • Strong interpersonal and communication skills (both verbal and written).
  • CMS and managed care knowledge preferred.
At Maxim Healthcare Services, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health, dental, vision, and life insurance
401(k) savings plan
Awards and recognition programs
  • Benefit eligibility is dependent on employment status.
Maxim Healthcare Services is a leading provider of home healthcare, medical-related staffing, travel nursing, and population health and wellness services across the United States. As an established community partner, we have been making a difference in the lives of our employees, caregivers, and patients for more than 30 years. Our commitment to customer service, improving patient care, and staffing experienced healthcare professionals has paved the way for many rewarding career opportunities in the healthcare industry.

Maxim Healthcare Services, Inc. is an Affirmative Action/Equal Opportunity Employer