Transitional Care Management Coordinator - Hybrid / Dawsonville

We are seeking a compassionate and organized Transitional Care Management Coordinator to join our team in Dawsonville. Clinical background required, Medical Assistant or LPN preferred This role focuses on supporting patients during transitions of care, typically when they move from one healthcare setting to another, to reduce complications, avoid readmissions, and ensure patients follow their care plans. Benefits: Medical, dental, vision, short/long term disability, 401k, PTO, life insurance, critical illness, hospital indemnity, and holiday pay. Monday-Friday, 8AM - 5PM, no nights or weekends. The position will transition to a hybrid role (4 days remote / 1 day in the Dawsonville office) after one month of hands-on training. Duties may include but not limited to:

• Contact patients within 24-48 hours after discharge from a hospital, skilled nursing facility, or rehabilitation center to confirm the patient understands their discharge instructions and assess immediate health concerns or complications.
• Ensure all providers have updated information about the patient's condition and care plans.
• Perform medication reconciliation.
• Review the patient's medications after discharge and ensure prescriptions from the hospital match the outpatient treatment plan.
• Arrange follow up visits within required timeframes (often 7-14 days) and remind patients about upcoming appointments.
• Document all patient interactions within our EMR system and ensure compliance with billing and documentation standards.
• Provide patient education to prevent complications or readmissions.
• Communicate both with staff, providers, insurance companies, reference labs and other medical practices as needed.
• Assess urgency of patient symptoms/ side effects and manage appropriately, including scheduling urgent appointments, referring to the Emergency Department, or activating EMS if necessary.
• Handle physician tasks, lab/test orders, medication refills, and update medication profiles.
• Efficiently manage patient charts and tasks within our EMR and hospital portals.
• Escalate complex issues to senior staff or management as necessary.

Requirements:

• Clinical background required, Medical Assistant or LPN preferred.
• Dependable, positive, and friendly team player
• Ability to thrive in a fast paced environment

Heart and Vascular Care is a practice that places a priority on compassionate patient care and service. We strive to set a new bar for patient healthcare through a modern, friendly, and thoughtful approach. Come be a part of our growing team. Apply and someone will be in touch! Apply tot his job Apply To this Job