Job Details

Job Title:

Transition of Care / Discharge Coordinator – Ambulatory (Epic / UR)

Hourly/Salary Compensation Range:

18-20/hr

Location:

• 100% Remote
• Supports Pacific Time Zone
• Candidates must reside in MST or PST time zones

Hours:

• 7:30 AM – 3:30 PM PST
• Rotational weekends (approximately every couple of weeks)
• Holidays required

Start Date:

6/22/2026

Job Description / Summary

The Transition of Care / Discharge Coordinator coordinates and implements the Transition of Care (TOC) / Discharge (DC) plan for ambulatory patients. The role prioritizes and coordinates discharge planning through critical thinking, teamwork, and effective communication with providers, patients, families, and external vendors to support timely, safe discharge and appropriate post-discharge care.

Management reserves the right to revise the job description or assign additional responsibilities based on operational needs.

Key Job Accountabilities

Collaboration with Care Coordination Team

• Partner with Case Managers and Social Workers to:
  • Assess baseline patient needs
  • Identify post-hospital support requirements
• Support development and execution of the TOC plan, including:
  • Communicating provider options and available resources
  • Clarifying expected discharge timelines
• Ensure patients and facilities understand benefit coverage; coordinate with payers as needed
• Monitor progress toward TOC goals and escalate barriers to Case Managers and Social Workers
• Keep patients and facilities informed of TOC plan progression
• Coordinate post-discharge referrals and authorizations
• Communicate referral status and barriers throughout the day to support timely discharge
• Facilitate patient transfer to post-acute facilities, including:
  • Preparing documents
  • Obtaining physician signatures
  • Coordinating transportation

Departmental Goals & Objectives

• Round with Case Managers and Social Workers to provide updates and receive direction
• Deliver Medicare “Important Message” (IM) and educate patients/facilities on appeal rights
• Proactively identify and escalate barriers to discharge
• Participate in daily huddles and department meetings
• Contribute to team prioritization and problem-solving
• Collaborate on interdependent tasks and demonstrate flexibility
• Share knowledge and foster collaborative relationships

Communication & Documentation

• Maintain accurate and timely documentation per department standards
• Enter Care Coordination notes in the EMR (Epic; Allscripts for closing discharge cases)
• Document patient/facility preferences and key decisions
• Enter final post-discharge provider information and close discharge cases in Allscripts
• Provide clerical support as needed (copying, faxing, scanning, data entry)
• Complete required department reporting forms

Customer Service

• Demonstrate professionalism and respect in all interactions
• Build positive relationships with internal and external partners
• Resolve issues effectively and escalate quality/risk concerns as needed
• Comply with HIPAA and confidentiality standards when transmitting patient information

Skill Set Requirements

• Required:
  • Epic EHR knowledge and experience
  • Experience with UR transmission
  • High-volume fax management
  • High-volume voicemail management
  • Data entry experience
  • Willingness to work rotational weekends and holidays
  • Strong written and verbal communication skills
  • Effective interpersonal and time management skills
  • Ability to work in a fast-paced environment with shifting priorities
  • Ability to work independently with minimal direction
  • Strong prioritization and discretion
  • Intermediate PC and word processing skills
• Preferred/Nice to Have:
  • Experience with Allscripts
  • Prior work in care coordination, discharge planning, or case management support in healthcare
  • Experience delivering Medicare IM or similar regulatory notices

Education / Certifications / Licenses

• High School Diploma or equivalent experience required