Transition of Care Clinician

Employment Type

: Full-Time


: Miscellaneous

MMM of Florida, a proud member of the InnovaCare Health family of companies, a powerful combination and the foundation upon which we're expanding. InnovaCare Health is the 9th largest Medicare Advantage provider in the U.S. MMM of Florida is a licensed HMO, NCQA accredited, that serves individuals enrolled in Medicare Advantage plans. Join us, this is an exceptional opportunity to do innovative work for the benefit of those we serve. The Transition of Care (TOC) Clinician supports and coordinates care transitions during a hospital event. The TOC Clinician ensures adequate and appropriate care transitions from a hospital setting to the next level of care. They interact with members, families, caregivers and care teams to facilitate care transitions from the hospital to a post-acute inpatient setting to included Skilled Nursing Facility (SNF); Acute Inpatient Rehab (AIR or IRF); Long Term Care hospitals ((LTAC); or directly to the member’s home or back into a community setting. The goal of a TOC Clinician is to anticipate, prepare and support hospitals in transitioning members from a hospital event in a way that drives positive experiences for the member and provider; results in efficient coordination and ensures the appropriate level of care to meet the clinical needs of our members. They help bridge gaps in discharge coordination and facilitate and ensure smooth internal and external handoffs and partnerships across the organization to support a member-centric approach to care transitions. Duties & Responsibilities may include:
  • Reviews daily census to identify members in an inpatient medical/surgical/behavioral setting that may require post-acute care to include either a secondary level of care (SNF, etc.), home health support and/or other outpatient services to avoid an unnecessary readmission.
  • Obtains member referrals from Concurrent Review Nurses identified as high risk.
  • For members that qualify, reviews the member’s record, collaborates with the concurrent review clinician and/or PCP to know actual health status and discharge date.
  • Conducts a telephonic or onsite health assessment with member, facility discharge planner, caregiver and physician, to identify member’s needs.
  • Approves requests that meet the eligibility, benefit coverage & medical necessity criteria.
  • Identifies and directs care to in-network providers.
  • Incorporates member and family preferences, and strengths into a collaborative plan of care.
  • Responsible for discussing the plan with member, family and physician.
  • Advocates, informs, and educates members on services and benefits.
  • Develops and/or updates individualized care plan for members.
  • Coordinates care across settings and providers.
  • Identifies and facilitates access to community resources and social services.
  • Monitors provision of services and benefits to ensure follow- up.
  • Schedules or facilitates scheduling of appointments and follow – up services
  • Request consultation and diagnostic reports from network specialists.
  • Conducts medication review.
  • Provides education, acts as an advocate and facilitates access to needed services and resources.
  • For services requiring authorizations, responsible to obtain in advance needed forms with required signatures and necessary information. 
  • Knowledge of medical necessity criteria, as well as Medicare Regulations and other established clinical guidelines, in order to make a coverage determination and coordinate care.
  • Responsible for processing authorizations for the identified services as per authorization policies and procedures.
  • Accountable to notify all parties of the services approved and the authorizations numbers.
  • In collaboration with the hospital discharge planner, assist in the coordination of approved services in advance.
  • Participates in case rounds with the multidisciplinary team to assure adequate and appropriate member’s care.
  • Monitors, modifies and updates the discharge plan to assure a timely discharge between all levels of care.
  • Perform follow-up calls as established policy and procedure to avoid interruptions of care.
  • Refers Member to internal programs or delegated entities to base on established criteria. Perform productivity report on daily basis or as necessary.
  • Conducts On-Call to assure that members and providers have access to Health Plan licensed clinical staff 24 hours per day seven days a week. To provide coverage for review of admissions discharge planning during after-hours, weekends, and holidays. To proactively manage discharges, continued stays and facilitate transfers to the most appropriate setting for continuity of care.
  • Manage all department incoming calls from PCP, providers, hospital discharge planners, members or caregiver in a politely, courteously and professional manner.
  • Informs the appropriate physician(s) when a Member does not appear to be functioning adequately at the outpatient level and coordinates any follow-up the physician(s) may request.
  • Carry a mobile phone with e-mail access that can be available for consultation or emergencies. Carry a laptop with access to company systems to provide coverage to On-Call services.
  • Documents all interventions in the system application including the selected criteria to determine the services request, clinical and/or social justification to bring and expand any service or transition of care according to the established policy, guides and procedure, variances on care, and other important information to demonstrate the current follow-up, clinical quality outcomes and cost effective impact of the discharge planning process.
  • Adheres to department policies related to the care of the SNPs members as follows: Attends all required initial and annual trainings related to the MOC such as care management, ICP, ICT and health assessment. Notifies supervisors of any processes not in compliance with the SNP’s policies and MOC requirements.

    Required: Active Florida LPN RN, LCSW or other equivalent clinical license in a behavioral health field. Three to five years clinical, psychiatric and/or substance abuse health care setting, home care or discharge planning required. Preferred: Experience in managed care setting. CCM certification preferred.


  • Current Florida driver’s license and vehicle available to drive for work between locations if necessary.
  • Must have excellent clinical knowledge.
  • Demonstrate communication, negotiation, and leadership skills.
  •  Ability to solve problems, make decisions and take action in partnership with other members of the healthcare team.
  • Ability to manage changes effectively, set priorities and organize activities when faced with competing demands.
  • Possesses a basic understanding of applying clinical criteria when determining medical necessity.
  • Broad clinical knowledge of the medical, psychosocial needs of the elderly.
  • Computer literate in Microsoft Windows applications, software and Internet.
  • Excellent verbal and written communication skills.
  • Availability to work extended hours as needed.

  • English required. Bilingual (Spanish/English) preferred. Ability to read, analyze, and interpret general business operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

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