The Transitional Care Coordinator (TCC) coordinates seamless care transitions from one level of care to another. The coordination of care is accomplished through collaboration with the patient, family members, acute and post-acute interdisciplinary teams, and home care. The goal is to optimize patient care transitions thereby reducing unnecessary utilization of services and decrease the risk of readmission. The applicant is knowledgeable about disease, treatment, available community and governmental resources, psychosocial implications for individuals and families, provides appropriate interventions and discharge planning services to the patients and families; Performs all other duties as assigned by Case Management Manager. The TCC will demonstrate careful professional and clinical judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, flexibility, and the ability to multi-task. In addition to the above, the TCC will stay up to date in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent continuum of care topics. Functions as liaison between patient/hospital and outside agencies regarding discharge arrangements as well as social issues Initiates referrals to nursing facilities home health agencies acute rehabilitation facility LTAC hospital and DME vendors as directed by the Case Manager Consults with Case Manager regarding the patient placement process and referral outcomes Communicates barriers and keeps Case Manager apprised of issues and progress Represents the needs and preferences of the patients and families during the referral process Contacts third party review agencies as necessary to obtain patient-specific information and prior authorization to appropriately advocate for the patient Completes continuity of care (COC) or PSSAR document with identified post hospital facility agency Assists with pre-authorization and eligibility for services Communicates with home care post-discharge care facilities and other agencies as relates to patient placement needs Required: Bachelor’s Degree, highly preferred, but not required in Social Work, Psychology, Sociology or Human Services; Preferred: 1 year of health care experience with discharge planning or care coordination experience