Clinical Care Coordinator
27 days ago
Fresno
Clinical Care Coordinator Los Angeles, CA (Hybrid) The Clinical Care Coordinator – LTAC Transitions facilitates safe, timely, and well-coordinated transitions of patients from Long-Term Acute Care (LTAC) settings to lower—but medically appropriate—levels of care, including skilled nursing facilities, subacute units, or home and community-based programs. Working within a hybrid model, the Coordinator spends designated days on-site at partner LTACs to participate in care rounds, engage with discharge planners, and coordinate directly with facility teams, while performing administrative and follow-up tasks remotely on non-onsite days. This position serves as the operational bridge between LTAC staff, Presidium providers, external facilities, and community partners—ensuring continuity, compliance, and strong communication across all transitions of care. Compensation & Schedule Compensation: $60,000 – $90,000 annually Schedule: Full-time Benefits: 3 weeks paid time off (2 weeks + 6-7 federal holidays), 401K, Medical, Dental, and Vision. Onsite (LTAC-Facing) Responsibilities • Attend scheduled onsite days (typically 2–3 per week) at assigned LTAC facilities., • Participate in interdisciplinary rounds and discharge planning meetings on behalf of Presidium., • Serve as the point of contact for LTAC case managers, social workers, and clinical staff regarding patients attributed to Presidium., • Review provider discharge readiness decisions and ensure orders, documentation, and authorizations are initiated promptly., • Identify barriers to discharge (e.g., authorization delays, placement availability) and escalate to the Director of Care Management or supervising provider., • Support family and caregiver education on post-discharge instructions, follow-up appointments, and care continuity resources. Remote (Administrative & Follow-Up) Responsibilities • Complete discharge documentation, coordination notes, and communication logs in the EHR or designated coordination platform., • Arrange logistics including transportation, DME, pharmacy coordination, home health orders, and post-discharge appointments., • Communicate with SNFs, home health agencies, and community partners to ensure readiness to receive the patient., • Confirm successful transfers and monitor members for 30-day readmission or escalation risk., • Conduct post-transition outreach calls to verify continuity and patient satisfaction., • Collaborate closely with Presidium providers and interdisciplinary teams to align discharge plans with the patient’s clinical needs and social circumstances., • Communicate proactively with health plans or managed care organizations to confirm authorizations or clarify next-level placement requirements., • Participate in internal quality-improvement initiatives focused on readmission prevention and transition efficiency., • Ensure all transition and coordination notes are entered within 24 hours of activity., • Track and report transition status metrics (timeliness, barriers, outcomes) through dashboards or assigned templates., • Support monthly performance review meetings by providing updates on active transitions, resolved barriers, and quality indicators. Education & Licensure Requirements • Preferred: Licensed Vocational Nurse (LVN) or equivalent clinical training., • Minimum: Associate degree in Nursing, Health Sciences, Social Services, or related field; or equivalent combination of education and healthcare coordination experience., • Desirable: Bachelor’s degree (BSN, BA/BS in Health Administration, Public Health, or Social Work)., • Valid California driver’s license and reliable transportation (for travel to partner LTAC facilities). Experience Requirements • Minimum 3 years’ experience in care coordination, discharge planning, or case management within LTAC, acute hospital, SNF, or managed-care environment., • Experience coordinating services and authorizations with health plans, providers, and community partners., • Familiarity with CalAIM, ECM, or Community Supports preferred., • Strong interpersonal skills with the ability to communicate effectively across clinical and administrative teams., • Highly organized with the ability to manage multiple transitions and shifting priorities in a fast-paced environment.