Transitional Care Monitoring (TCM) Coordinator - CINQCARE

Grace at Home Primary Housecalls is now part of the CINQCARE family.

About You

Integral to the team, you will coordinate the TCM program and working collaboratively across a multi-disciplinary team, you will contribute to the development, implementation, and on-going refinement of the transitional care processes

• Education:
  • Completion of a Medical Assistant (MA) program.
  • MA certification or eligible to become certified as an MA
• Experience:
  • Proficient in basic computer skills including excel
  • EHR experience a plus
• Communication: Excellent verbal, written communication and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner to CINQCARE’s team, investors, partners, and other stakeholders. Proficiency in all Microsoft Office applications.
• Relationships: Ability to build and effectively manage relationships with business leaders and external constituents; and,
• Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.
• Entrepreneurial: CINQCARE seeks to fix gaps that have persisted for generations in the delivery of care to Black and Brown populations. This position is accountable for ensuring CINQCARE is positioned to innovatively deliver on its promise.

About the Job

• Facilitate TCM by Identifying patients who have been admitted to an inpatient or skilled nursing facility.
• Track admission and work with hospital and skilled nursing facility staff to track admission and facilitate discharge planning.
• Maintain tracking tools and update patient charts with updates on patient status.
• Contact patients post discharge and assist scheduling department with getting patient scheduled per their TCM visit cadence and ensure patient visits follow the designated cadence.
• Follow up phone calls post discharge to assess for patient needs and gaps in care and facilitate patient needs.
• Work to find SNF placement for treatment in lieu of ER visits and hospitalizations to reduce hospital utilization when appropriate.
• Facilitate faster hospital dc to SNF for rehab by leveraging SNF partner to find open beds and arrange admission faster.
• Facilitating patient needs to ensure they have the medication, care orders and DME they need upon returning home.

CINQCARE provides all employees working an average of 30+ hours/week with the option to enroll in healthcare benefits. The cost of healthcare is shared between the company and the employee.

The working environment and physical requirements of the job include:

This position requires both in-home and office-based work. In-office work is performed indoors in a traditional office setting with conditioned air, artificial light, and an open workspace.

In this position you will need an ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 30 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.