At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission.

Job Summary

The Transfer of Care Coordinator (TCC) plays a critical role in ensuring continuity of care for patients following hospital, emergency department, or skilled nursing facility visits. The TCC proactively engages patients post-discharge to facilitate timely follow-up appointments, address barriers to care, and support transitions back into outpatient settings. In addition, the TCC is responsible for screening and enrolling eligible patients into the Enhanced Care Management (ECM) program, connecting them to long-term, wraparound services.

Supervisory Responsibilities: None

Essential Duties/Responsibilities

• Identify and track patients discharged from acute care settings to ensure timely primary or specialty care follow-up
• Collaborate with hospitals, discharge planners, and community partners to obtain discharge summaries and care instructions
• Contact patients by phone, telehealth, or in-person to schedule and confirm post discharge visits
• Educate patients and caregivers on the importance of follow-up, medication management, and red flag symptoms
• Use Epic and other tools to document all care coordination activities
• Screen patients for eligibility and facilitate enrollment into the Enhanced Care Management (ECM) program
• Coordinate with ECM, Referral Coordination, Social Services, and other internal teams to remove barriers and ensure holistic care
• Track and monitor appointment compliance and escalate concerns to clinical teams as needed
• Support quality initiatives related to hospital readmission prevention and HEDIS metrics
• Attend care team meetings to support patient transitions and follow-up planning
• Maintain HIPAA compliance and proper documentation standards
• Perform other duties as assigned

Required Skills/Abilities

• Knowledge of case management or care coordination practices
• Understanding of social determinants of health and wraparound service models
• Proficiency in EMR systems (Epic preferred)
• Excellent communication, follow-through, and customer service skills
• Strong organizational skills and ability to manage multiple priorities
• Bilingual in Spanish preferred

Education and Experience

• Experience with transitional care and hospital discharge processes preferred
• Familiarity with ECM program guidelines and Medi-Cal benefits is a plus

Working Conditions/Physical Requirements

• This position is on-site at DAP Health Sunrise
• Ability to lift 24 pounds
• Operates in an office/clinical setting, frequent use of phone and computer systems