The Transitional Care Coordinator (TCC) is responsible for managing a patient's successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk patients. He/she is responsible for managing the post-acute care of patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. The TCC develops and modifies a patients' post-acute care plan and identifies any barriers to the post hospital plan of care. Ensures appropriate next site of care for patients using evidence-based decision support tools including InterQual level of care criteria. In managing patient care transitions between inpatient and outpatient settings, serves as a liaison to the acute clinical team, case managers and social workers as well as the patient and family members. The TCC has a sound clinical knowledge base, understands utilization management, case management, post-acute transitions, and home health. Knowledgeable regarding Medicare, Medicaid and commercial payer regulations. The TCC is collaborative in Acting as a consultant to the outpatient area, this role will help the medical teams explore outpatient alternatives to acute hospitalization (home health, home infusion, SNF placement, etc.) The TCC will work closely with inpatient case managers to efficiently manage care transitions and discharge from acute hospitalization. The TCC manages post discharge phone calls through Cipher Health system and will triage calls according to established algorithms and workflows. Refers to appropriate healthcare team members, providing consultation as needed. Provides clinical supervision for the LVN Discharge Planning Coordinators and delegates follow up calls.

Essential Duties:

CLINICAL CASE MANAGEMENT ASSESSMENT 1. Applies advanced critical thinking and conflict resolution skills using creative approaches to management of patient load. 2. Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning. 3. Critically evaluates and analyzes physical and psychosocial assessment data. 4. Initiates and maintains communication and collaboration with the inpatient and outpatient interdisciplinary teams and, and patients/families to manage a smooth and seamless transition for patients identified as high risk for readmission. 5. Utilizes financial and insurance resources as well as Keck Medicine of USC assistance programs (i.e. Medical Assistance Program) to maximize the health care benefit to the patient. 6. Assesses complexity of care needs and potential/actual issues or gaps in care. 7. Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services. 8. Advocates for patients and families within the health care system with community providers and across the continuum of care 9. Identifies, tracks, and conducts root cause analyses on 30-day readmissions to address programmatic and system-wide improvements. 10. Works with the interdisciplinary team and researchers to identify broader system issues affecting readmissions. 11. Identifies financial barriers that will affect the individual’s ability to receive appropriate healthcare services.TRANSITIONAL CARE COORDINATION 1. Responds timely to requests from managed care partners for referrals for specialty outpatient services 2. Collaborates with clinic staff to make referrals for home health, home infusion, DME and other outpatient services 3. Works collaboratively with Patient Navigators to assist patients with accessing needed services. 4. Knowledgeable regarding current scope of specialty outpatient services / treatments and physicians. 5. Serves as a consultant to medical staff and clinic personnel regarding available outpatient services 6. Proposes alternatives to acute hospitalization as appropriate. 7. Works with inpatient case managers to proactively identify discharge barriers and effectively manage care transitions from discharge to outpatient. 8. Collaborates with Medical Staff to effectively manage care transitions from outpatient to inpatient setting for at risk patients. 9. Develops creative solutions to discharge barriers 10. Proactively works to identify opportunities to improve patient access and offers potential solutions. 11. Identifies patients at high-risk for readmission utilizing Cerner Readmission Module.CIPHER HEALTH POST DISCHARGE TRIAGE CALLS 1. Provides consultation for maintenance, evaluation and revision of Cipher Health algorithms and workflows for post discharge phone calls 2. Triages post discharge phone calls according to algorithms and workflows, 3. Provides clinical supervision of LVN Discharge Planning coordinators involved with post discharge phone calls. 4. Ensures timely response and appropriate escalation for patient concerns identified with post discharge phone callsREGULATORY 1. Adheres to regulatory requirements as defined by CMS Conditions of Participation, California Department of Public Health, The Joint Commission, and the California Department of Insurance as reflected in hospital policies and Care Coordination Department processes. 2. Works with RN case managers, social workers and LVN discharge planning coordinators and physicians to ensure Patient Choice is established, facilitated and documented to the extent possible when post-acute services are needed according to hospital policy Patient Choice for Post-Acute Services. 3. Educates the patient / patient representative regarding their Medicare Appeal Rights per the Important Message from Medicare and according to the Keck Important Message from Medicare Policy.DOCUMENTATION 1. Provides routine verbal and written documentation of transition of care, care coordination and Cipher Health activities. 2. Projects costs and needs for the future and provides cost analysis for patients that require advanced care planning and cost sharing by Keck Medicine of USC when the patient is unfunded or underfunded.RESEARCH 1. Demonstrates knowledge of evidence – based research findings related to Transitions of Care. 2. Participates in activities that support the advancement of care transitions, case management, and discharge planning through literature review, professional organizations, research, committee participations, etc. Consistently uses new knowledge, technology, and research in practice. 3. When appropriate, participates in discussions regarding evidence-based care transitions identifying recurring clinical practice issues and contributes to the development of specific plans to address identified issues.PROFESSIONAL DEVELOPMENT 1. Provide educational offerings in the transitions of care arena within the Keck Medicine of USC high performance post – acute network. 2. Serves as a liaison between the Care Coordination Department, other Keck Medicine of USC outpatient divisions and in the community. 3. Monitor and improve quality of services provided to patients/families through ongoing participation in team and departmental quality improvement activities. 4. Serves as a consultant to the healthcare team.QUALITY AND STANDARDS 1. Adheres to hospital and department protocols, workflows, policies, procedures, standards and competencies for clinical role 2. Participates in InterQual competency training and testing as requested by department Director. 3. Participates in hospital quality improvement processes and helps identify opportunities to improve care. 4. Strives to support and contribute to the success of the department outcome metrics, key performance indicators and department goals and objectives. 5. Identifies compliance and ethical issues and reports appropriately. 6. Participates in clinical performance improvement activities to achieve set goals. 7. Adheres to mission, vision and values of organization.EDUCATION 1. Participates in the orientation of new department staff. Provides learning opportunities for students in various health care disciplines as requested. 2. Supports the Keck Medicine of USC high performance post – acute network outreach mission through consultation and/or education of community. 3. Maintains awareness of own professional development needs and communicates these needs by setting annual performance goals.COLLABORATION 1. Collaborates with the individual, family, healthcare team, payors, community agencies, providers, and legal representatives to ensure continuity of the individual’s care through all healthcare settings. 2. Promotes effective communication among healthcare team members, including the individual, family and payors and employer when appropriate. 3. Participates in team meetings when indicated. 4. Incorporates recommendations and / or services of interprofessional team members in plan of care. 5. Communicates with other case managers along the continuum of care for coordination of the needs of the individual if case management involvement is limited by setting. 6. Conveys a positive attitude toward work-related responsibilities as demonstrated by tolerance of fluctuating priorities in a fast-paced environment. 7. Works as a team member within care coordination and Keck. 8. Supports the needs of the department with other duties as assigned and / or delegated.Performs other duties as assigned.

Required Qualifications:

Req Master's degree Graduate from an accredited school of Nursing (MSN).Req 5 years Nursing in an acute care setting.Req Must demonstrate ability to work both independently and cooperatively in a team as needed and follow-up towards the successful completion of assigned tasks.Req Organization/time management skills.

Preferred Qualifications:

Pref 1 year Case Management in an acute care or outpatient setting.

Required Licenses/Certifications:

Req Registered Nurse - RN (CA Board of Registered Nursing)Req Nurse Practitioner - NP (CA Board of Registered Nursing)Req Nurse Practitioner Furnisher (CA DCA) Current license to furnish medications in the State of California.Req DEA Certificate Drug Enforcement Agency (DEA) Certificate issued by the U.S. Department of Justice for Schedule II-V controlled substances.Req NP Board Certified Possession of National Board Certification in Nurse Practitioner area of specialty accredited by Accreditation Board of Specialty Nursing (ABSNC) or National Commission for Certifying Agencies (NCCA). ◦ If work in Hospital/Acute Care Setting must have Certification from the American Nurses Credentialing Center (ANCC) or American Association of Critical-Care Nurses (AACN) as an Acute Care Nurse Practitioner (ACNP) or Adult Gerontology Acute Care Nurse Practitioner (AGACNP) upon hire. ▪ (*Grandfathered from Acute Care Certification requirement if hired/transferred prior to 12/2015.)Req Basic Life Support (BLS) Healthcare Provider from American Heart AssociationAdvanced Cardiovascular Life Support (ACLS) Healthcare Provider from American Heart Association ◦ ACLS as required by the NPs Job description for NPs in the Hospital/Acute Care Setting and Ambulatory Infusion CentersReq Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
The annual base salary range for this position is $133,120.00 - $219,648.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.