Transitional Care Coordinator, Praxis Health

Praxis Health is seeking a dedicated and compassionate Transitional Care Management (TCM) Coordinator to oversee and facilitate the transitional care process for patients moving between healthcare settings. The TCM Coordinator will play a crucial role in ensuring continuity of care, reducing hospital readmissions, and promoting patient wellness during transitions. The ideal candidate will possess an LPN or RN license, have strong organization skills, clinical expertise, and a commitment to patient-centered-care.Schedule Full-time, Monday - Friday; this position is 100% remoteCompensation Experienced candidates with job readiness will begin $25/hourCheck out this short video that shows why the Praxis Health family is so special. Please click here https//youtu.be/MrNWtn42prYBenefit HighlightsMedical, Dental, Vision with In-Network & Custom Network discounts401(K) with discretionary employer matchPaid Time OffFree clinical diagnostic laboratory testing performed in houseResponsibilitiesFollows up with patient after hospital discharge, post unexpected hospital admission, or patient who is discharged from a skilled nursing facility, rehab facility, or short-term acute care facility.Gathers hospital discharge information, such as admitting diagnoses, procedures performed, dates admitted, medication changes, and follow up appointments needed.Calls the patient to assess their condition since returning to their place of living; verifies medication changes, follow up appointments, whether home health was ordered or not, and any new medical devices ordered; answers any questions or concerns the patient may have or directs those questions to the provider; and attempts to schedule the patient with their primary care provider within two weeks from the date of discharge.Records the pertinent information into the patient’s health record for the provider to review.Collaborate with healthcare providers, including physicians, nurses, social workers, and care managers to coordinate post-discharge plans.Facilitate communication between patients, caregivers, and healthcare teams to ensure understanding and adherence to care plans.Ensure accurate and timely documentation of transitional care activities, patient assessments, care plans, and outcomes.Maintain compliance with regulatory standards and guidelines related to transitional care management and patient safety.LPN or RN license from an accredited institution.Clinical experience in healthcare settings, with knowledge of transitional care management principles and practices.Proficiency efficiently maneuvering in electronic health records (EHR) systems and medical documentations practices.Demonstrated record that would ensure candidate can be trusted with personal health information working remotely.Use of Greenway Intergy preferred. Must be able to navigate multiple EMR/EHR systems.Other RequirementsMust possess a current CPR certification and current health records with the appropriate immunization to work in the health care field (Hepatitis B and Tuberculosis).Praxis Health is a family of medical groups providing high quality healthcare throughout the state of Oregon. Our community-based clinics are the DNA of our business, providing better medicine, advocacy for our patients, and a satisfying and collaborative culture for our providers and staff.The Praxis family approach is dynamically different than other healthcare companies in Oregon. We are not “big box” health care, but rather a company of small groups and clinics, of nimble micro-cultures that can quickly adapt to industry changes, as well as patient needs.We have been serving communities across the beautiful and adventurous state of Oregon for over 50 years! And we are pioneers and thought leaders in the industry. Our commitment to innovative and operational excellence has allowed us to create healthcare solutions that are both cost-efficient and cutting edge.Come see how healthcare is done right!Physical DemandsManual dexterity for office machine operation including computer and calculator; stooping, bending to handle files and supplies, or sitting for extended periods of time.Stress can be triggered by multiple staff demands and deadlines.Work EnvironmentHome office.EOE Disabled/VeteranPraxis Health is an Equal Opportunity Employer and provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.