Care Coordination, Transition of Care (TOC)

At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together.

Umpqua Health strongly encourages applications from candidates of color as well as veterans, aiming to foster a work environment that is linguistically and culturally diverse and inclusive. Please note that at this time, Umpqua Health does not offer visa sponsorship.

The Care Coordination, Transition of Care is responsible for ensuring a smooth transition for patients moving between levels of care, from one healthcare setting to another, or returning home after hospitalization. This role involves working with patients, families, healthcare providers, and community resources to facilitate comprehensive care planning, education, and follow-up to improve patient outcomes and reduce readmissions. 

• Collaborate with interdisciplinary teams to develop, implement, and monitor individualized transition of care plans.
•   Assess patients’ and caregivers’ needs, preferences, and goals during care transitions.
• Coordinate and schedule follow-up appointments, tests, and procedures as required.
• Serve as the primary point of contact for patients and families during transitions, providing clear instructions and answering questions.
• Communicate relevant patient information to receiving healthcare providers to ensure continuity of care.
• Work with community resources, home health agencies, and other external partners to secure necessary services and support.
• Educate patients and their families on disease management, medication adherence, and self-care during the transition process.
• Provide resources and referrals to address social determinants of health, such as transportation, housing, or financial assistance
• Conduct post-discharge follow-up calls to assess patient status, address concerns, and reinforce care plans.
• Monitor high-risk patients closely to prevent hospital readmissions and emergency room visits.
•  Document all care coordination activities in the patient’s electronic medical record (EMR) accurately and timely

• Participate in quality improvement initiatives aimed at enhancing the transition of care processes.
• Analyze data related to care transitions and contribute to performance improvement strategies
• Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organization’s Values.

• Bachelor’s degree in nursing, social work, healthcare administration, or a related field
• Minimum of 2-3 years of experience in care coordination, case management, or a related healthcare role. Experience in transitions of care is highly desirable
• Current RN, LCSW, or related professional licensure is preferred. Case Management Certification (CCM, ACM) is an advantage
• Strong knowledge of care coordination principles, hospital discharge processes, and community resources.
• Excellent communication, organizational, and problem-solving skills.
•  Ability to work independently and as part of a multidisciplinary team.
• Proficiency in using electronic medical records (EMR) systems and other care management software.

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.