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Patient Transition Coordinator - Full-time

Allegheny Health Network

  • Company AHN
  • Pittsburgh, PA
  • Direct Patient Care Providers
  • Full time
  • Rotational (United States of America)

Company :

Allegheny Health Network

Job Description : 


This job facilitates and monitors the referral workflow from the acute care hospital setting to home.  The incumbent works directly with the Transitional Care Coordinator (TCC) to coordinate the patient’s post-acute care needs.  The incumbent works to complete their work in an effective, efficient, accurate, and timely manner to assure compliance with regulations.  This position requires strong computer and database management skills.  It also calls for flexibility, excellent interpersonal skills, project coordination experience, and the ability to work well with all levels of internal management and staff, as well as outside customers and vendors.  This position can be a career ladder position to the Transitional Care Coordinator (TCC) with proven record of ability.                                          


  • Referral acceptance -- organize, track, and build a complete medical record for appropriate patient transition to home and post-acute providers; obtains missing information, including all requirements to support care transition, initiation of service, equipment dispensing/delivery, and compliant billing. (20%)           
  • Referral processing -- responsible for completing the transition of care via established systems and processes (Epic, Allscripts ECIN, Jira, etc.). (20%)
  • Care coordination -- responsible for identifying all post-acute care needs and collaborating with the TCC, as well as internal (Healthcare@Home) and other partnered post-acute service providers. (10%)               
  • Equipment delivery -- assess needs of customers, explain options, deliver equipment to bedside, assure safe/appropriate sizing, and instruct customer and/or caregiver on use of HME dispensed. (10%)           
  • Service confirmation -- confirm start of care (SOC) by internal (Healthcare@Home) and external agencies for each patient referred via computer lookup, phone contact, etc.; appropriately escalate cases where SOC has been delayed or missed to assure that patients receive care as ordered and expected. (10%)     
  • Communication and reporting -- complete and process paperwork and enter notes promptly and accurately; manage and create general correspondences, memos, charts, tables, graphs, in order to package referrals and medical records in support of a smooth and effective transition of care. (5%)          
  • Education -- Interact with patients, families, clinical caregiver teams, and referral sources. (5%)             
  • Inventory management -- organize and maintain and all onsite equipment for consignment and dispensing. (5%)
  • Build and maintain relationships with post-acute and Hospital/network partners for the benefit of patients, families, and the health care team.  (5%)
  • Complete reporting as needed/assigned to reflect workflows and outcomes. (5%)
  • Other miscellaneous duties, e.g. participation in interdisciplinary process improvement efforts, huddles, and special projects associated with assuring effective care transitions and documentation. (5%)  



  • High school diploma/GED


  • Bachelor’s degree
  • Associate’s degree
  • 1-3 years experience in the medical profession
  • Valid driver’s license with excellent driving record

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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