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Date: Feb 7, 2018

Location: Newport Beach, CA, US

Company: Hoag Memorial Hospital Presbyterian

Job Description:

The Therapist/Transition Coordinator functions as an integral member of a multidisciplinary health care team. Coordinates the care of specific patient populations through the transition to adult medicine practitioners, as directed. Responsible for the planning, development, and implementation of the transitional care management activities for patients with complex conditions or multiple co-morbidities that place them at high risk. Assists in the creation of a network of primary care and specialty practices, and works in collaboration with that team to ensure a smooth transition from pediatric to adult care providers. Provides guidance to care team on best practices in transitional care management to optimize clinical and financial patient outcomes. Participates with other area specialists in the screening process to identify children who may have developmental concerns. Reviews screening results and utilizes data for the purpose of monitoring children’s progress. May refer children to appropriate intervention service providers. The scope of transition services includes assessing not only medical/health needs but also assessing the member’s social determinants of health and the development of an inclusive and realistic transition plan.


Essential Functions: Clinical and Physician Partnership

 Coordinates and develops concise patient summaries for use by care team by communicating regularly with treating clinicians and other members of the care team.

 Educates practitioners on the level of care and clinical documentation requirements.

 Compiles and gathers comprehensive clinical assessments that include medical, behavioral, pharmacy, social, and rehabilitation needs of each patient to implement the plan of care. Shares this information with the care team and others, as appropriate.

 Confers regularly with area specialists concerning learning concerns. Recommends and models appropriate strategies of behavior modification that will promote learning.

 Engage youth/young adults in identifying goals and needs.

 Work in collaboration with youth/young adult, their families, and clinical care team to develop and monitor care.

 Build and coordinate individualized service team for youth/young adults and their families.

 Provides transition care management by communicating and coordinating with the care teams, care coordinators, social workers, and others as necessary.

 Documents pertinent information related to transition process in electronic health records to support smooth transition from pediatric to adult practitioners

 Must have demonstrated ability in working with medical professionals and individuals experiencing mental health challenges and their families, knowledge of community resources, developing and maintaining relationships in the community, crisis intervention skills, and an ability to work with a multidisciplinary team.


Quality and Service

 Assists in the identification of high risk patients in need of clinical care management and proactive outreach. Works effectively with staff in primary care practices, accessing information from the electronic health record, and other information sources.

 Conducts transition planning activities for patients that have complex needs, chronic conditions, or who require preventative services. Collaborates with physicians, other care providers, Care Coordination, and community resources in the care planning. Establishes relationships with local legal and social work networks.

 Utilizes process to comprehensively assess the patient’s physical and psychological status. Evaluates progress of patients. Works with patients and their families on increasing patient autonomy and disease awareness.

 Reviews services currently received by each patient and identify gaps in care based on evidence-based clinical standards of care and the patient-specific care plan.

 Provides access to community resources and links to support services in collaboration with Care Coordination. Coaches other staff in coordination of care strategies as appropriate.  Directly provides coordination of transition services including but not limited to: follow up appointments, counseling services, and other clinical and non-clinical services. Assists patient and care team in accessing culturally appropriate, necessary, and community-based services.

 Assists patients in understanding their diagnosis, treatment options, and resources available. Evaluates and addresses patient concerns.

 Engages the family or other support sources for the patient as appropriate. Uses a combination of communication methods such as meetings, phone calls, email, or other tools to communicate with patients and/or their families.

 Incorporates patient- and family-centered care delivery and management methods.

 Promotes positive work environment which emphasizes respect to our patients, families, care team colleagues, support staff, and other departments and services.


Data and Research

 Prepare and maintain files, reports, statistics, etc. Provides reports as requested for internal and external tracking and review. May participate in preparing or delivering presentations to audiences at all levels of the organization.

 Creates and maintains patient database for research purposes.

 Complies with established departmental policies, procedures, and objectives.

 Attends variety of meetings, conferences, and seminars as required or directed.

 Demonstrates use of quality improvement in daily operations.

 Complies with all health and safety regulations and requirements.

 Respects diverse views and approaches, and contributes in maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.

 Performs other similar and related duties as required or directed.


Education, Training and Experience


Bachelor’s degree in healthcare-related field

Master’s Degree in Social Work (MSW)

Minimum of 2 years MSW experience, preferably in an acute healthcare setting or equivalent work experience


Skills or Other Qualifications


 Skilled change agent with a sensitivity to interpersonal, group dynamic, organizational, political and perceptual issues associated with change.

 Must have strong experience in Microsoft Office (Word, Excel, PowerPoint, and Access).

 Strong analytical, problem-solving and decision making capabilities.

 Basic computer skills required.

 Must be able to work independently while prioritizing workload.

 Excellent verbal and written communication skills.

 Strong attention to detail and ability to maintain confidentiality required.

 Experience and familiarity with electronic health records.

 Data compilation and analysis skills.


 At least 1 year of clinical care experience in coordinating care for individuals with complex needs including medical, behavioral, pharmacy, home care, discharge planning, and social needs required.

 Utilization management and third party payer knowledge



Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Database, Research, Technology

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