Transitional Care Management Coordinator

The Transitional Care Management (TCM) Coordinator supports patients during transitions from inpatient or post-acute settings to outpatient care. This role focuses on timely post-discharge outreach, care coordination, medication reconciliation support, appointment scheduling, and patient education to reduce avoidable readmissions and improve continuity of care. The TCM Coordinator works under the direction of licensed providers and care management leadership and in compliance with CMS Transitional Care Management guidelines.
PRINCIPAL DUTIES AND RESPONSIBILITIES
:
-
Identifies patients eligible for TCM services following discharge from hospitals, observation stays, or skilled nursing facilities.
-
Completes post-discharge outreach within 2 business days via phone or electronic communication. Verifies discharge instructions, follow-up needs, and patient understanding.
-
Coordinates and schedules follow-up visits with primary care and specialty providers within required timeframes.
-
Provides medication reconciliation support by reviewing discharge medication lists with patients and caregivers, identifies discrepancies, barriers to adherence, or refill needs, escalates medication concerns to providers per protocol and documents medication reconciliation activities in the EHR.
-
Provides standardized education on discharge instructions and follow-up care. Reinforce care plans and identifies social or logistical barriers (transportation, DME, home services) and works with care team to resolve.
-
Facilitates communication between inpatient teams and outpatient providers.
-
Documents all outreach, coordination, and patient education activities accurately in the EHR.
-
Work collaboratively with primary care, specialty practices, nursing, care managers, pharmacists, and social workers.
-
Participate in interdisciplinary huddles or case reviews as needed.
-
Support quality improvement initiatives related to readmissions and care transitions.
QUALIFICATIONS:
-
LPN or Medical Assistant certification required.
-
Minimum 1–2 years’ experience in ambulatory care, care coordination, or clinical support role.
-
Familiarity with outpatient workflows in a multi-specialty setting.
-
Strong communication, organizational, and patient engagement skills.
-
Proficiency with EHR systems and scheduling platforms.
-
Experience with Transitional Care Management or post-acute care coordination.
-
Knowledge of CMS TCM requirements and value-based care models.
-
Experience working across multiple specialties or service lines.
At Stamford Health, we believe that every patient deserves compassionate, personalized, person‑centered care. This commitment guides how we care for patients, support their care partners, and promote the wellbeing of our staff. In alignment with our Planetree philosophy, the individual in this role will foster a respectful, collaborative environment that honors the needs, values, and preferences of every person we serve and the colleagues we partner with.