JOB SUMMARY

Provides crucial operational support to the health plan's Utilization Management (UM) and Transition of Care team. The primary focus of this role is the management, reconciliation, and continuous daily updating of the inpatient admission census, ensuring accurate and timely data entry. Additionally, the Coordinator supports TOC workflows by gathering and reviewing clinical documentation (discharge summaries, progress notes, medical orders) and coordinating follow-up appointments and post-discharge services to ensure a safe and seamless care transition for health plan members.

ESSENTIAL FUNCTIONS

• Daily Inpatient Census Management
  Data Entry and Reconciliation: Maintain, update, and reconcile the daily inpatient census within the health plan's system based on reports received from facilities (via EDI, provider portals, or direct communication).
• Status Tracking: Monitor discharges, facility transfers, changes in level of care (e.g., ICU to step-down/floor), and readmissions to ensure accurate length-of-stay (ALOS) tracking.
• Clinical Support Escalation: Promptly identify and notify clinical team members (review nurses and case managers) of new admissions or priority cases requiring concurrent review.
  Facilitate operational reports required by the Management team.
• Transition of Care (TOC) Operational Support
  Clinical Document Collection: Request, retrieve, and upload essential post-discharge clinical documentation into the plan system (discharge summaries, medication reconciliation forms, post-care plans) and providers and members portals.
  Initial Administrative Review: Verify the completeness and legibility of collected clinical documentation prior to escalating to upload into the systems.
  Post-Discharge Appointment Coordination: Assist in scheduling and confirming follow-up appointments with Primary Care Physicians (PCPs) or specialists, ensuring member confirmation prior to or immediately following discharge.
  Services & Vendor Liaison: Facilitate coordination with Home Health Agencies, Durable Medical Equipment (DME) vendors, and sub-acute facilities according to clinical team guidance.
• Communication, Quality, & Compliance
  Interagency Liaison: Serve as an administrative point of contact between the health plan, hospital discharge coordinators, and contracted providers.
  Accurate Documentation: Meticulously log all interactions, document transmissions and status updates within the health plan platform to meet internal auditing and regulatory standards.
  Process Improvement: Identify operational bottlenecks in hospital data collection or notification processes and propose workflow enhancements and escalate to the management team for resolutions and action plans

EDUCATION

EXPERIENCE

• Bachelor’s Degree with six (6) months of experience in similar activities, or Associate degree or Technical Course with at least two-three (2-3) years of experience in operational support activities.
• Experience within a health plan organization, hospital admissions or care coordination is preferred.

LICENSES AND CERTIFICATIONS

COMPETENCIES