Transitions of Care Coordinator

Overview About us: Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality. Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region. Brief summary of purpose The Transitions of Care Coordinator uses a multidisciplinary approach to ensure that SE participant transitions of care to and from inpatient facilities are appropriate, timely, and successful. In collaboration with the SE IDT ascertains that participants are in receipt of high quality cost efficient care and outcomes Responsibilities Primary Job Responsibilities • Attends daily IDT meetings to discuss inpatients and suggest discharge plans• Utilize a checklist to ensure that the components of a safe transition of care occur• Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting• Participates in family meetings as needed• Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning.• Collaborate with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting • Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation • Acts as a liaison between facilities and IDT members to convey progress• Access resources out of network to meet participant needs• Utilize Collective Medical to track transitions in real time• Supports the fundamental mission of the Summit ElderCare program• Determines tier of service at subacute facilities• Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services• Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals • Knowledge of managed care, quality, and risk management principles• Participates in the SE Utilization Committee• Generate Ad Hoc request when…