Clinical Transitions Coordinator

UCM Digital Health   Troy, NY   Full-time     Health Care Provider
Posted on December 28, 2022
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UCM Digital Health (UCM) is a leading innovator in the digital health space, founded in 2015 by emergency medicine providers with the vision that all care should begin digitally. Our mission is to put the patient first with a best-in-class digital experience backed by emergency medicine expertise. Our digital front door platform, integrated technology, and 24/7 telehealth treat, triage and care coordination seamlessly connect digital and physical healthcare for patients. We deliver the right care, at the right time and place, and at the right cost for our more than 2 million patients and over 600 clients and growing.

Our solution is designed to lower costs, improve outcomes and provide a better patient experience. More than a digital front door, UCM brings together clinical expertise, advanced technology, and compassionate care to offer powerful advantages for health plans, employers, patients and providers.

We are looking for candidates who share our mission to put the patient first and our values of honesty, compassion, inquisitiveness, fearlessness, accountability, and teamwork. If you have an entrepreneurial spirit, thrive in a fast paced environment, and are ready to contribute to a growing company, come join our team! This is a great opportunity to be part of changing the game in healthcare!

Position Summary: 

UCM Digital Health has a terrific opportunity for a dynamic Clinical Transitions Coordinator (CTC) to join our team at a rapidly growing telehealth company. The CTC is responsible for ensuring that patients enrolled in UCM’s transition of care receive a highly coordinated, patient-centered, high quality and cost-efficient health outcome. This position will involve on-site and remote management of patients, coordination with a variety of providers and serving as a key conduit of information and coordination among all stakeholders for seamlessly integrated care. The CTC provides support to 1) the patient/family/caregivers 2) the hospital care team 3) community- based clinical teams and the 4) health plan by adhering to standardized workflows and data sharing that support appropriate care planning.

Success in this position will depend on exceptional communication skills, excellence in coordinating care and patient advocacy, and attention to detail. Critical for success as the Clinical Transitions Coordinator in the ability to represent UCM’s transition of care programs confidently and enthusiastically to convey the benefits to health care professionals whose collaboration is necessary for success. As the “face” of the program, the ability to “win over” needed collaborators is paramount. Success will require the ability to navigate and integrate with the multi-disciplinary hospital emergency department and inpatient unit staff hierarchy and become accepted as “part of the team.” The ability to display competence in understanding a patient’s clinical circumstances and treatment plans is essential to success in this role. Candidates for this role may include nurses, social workers, paramedics or similarly licensed or certified healthcare professionals. Sales and marketing experience will add to the likeliness that you’ll be a great fit for this role. A passion for reducing avoidable readmissions and avoiding unnecessary emergency department utilization will set you apart.

Position Objectives:

The Clinical Transitions Coordinator position coordinates UCM’s efforts to prevent avoidable hospital readmissions and emergency department visits through optimal discharge planning, patient education, post-discharge support and clinical coordination across the continuum of care. The Clinical Transitions Coordinator will partner with the hospital, health plan, and UCM providers to initiate activities that are designed to support the patient and family in a successful transition from hospital-to-home. This includes appropriately referring patients into both medical and non-medical services to support ongoing wellness and utilizing hospital, health plan, and community-based care management resources and programs. The ultimate objective of this position is to prevent avoidable hospital readmissions by serving as an intermediary to close gaps in medical, nutritional, social, or logistical needs.

Summary of Responsibilities:

  1. Collaborates with hospital, health plan, and PCP discharge planning/transitions and evaluates patients’ appropriateness for program inclusion using patient identification criteria. 
  2. Responsible for collecting and verifying complete patient demographic information in electronic medical record (EMR).
  3. Initiates face-to-face or virtual patient transition to begin identification of post-discharge needs and educates the patient/family/caregivers on the readmission reduction program.
  4. Initiate and complete encounter intake documentation in EMR to ensure all patient needs are documented.  and met by the program. Document initial encounter note within 24hrs of first patient contact.
  5. Educates patient on the importance of the post-discharge program follow up appointment & involves the family caregivers in the educational process, assesses post-discharge educational coaching needs, and introduces patient family to the program; assures patient and family have program contact information.
  6. Ensures that the patient/caregivers are educated on obtaining all necessary prescriptions prior to discharge from hospital and confirms patient's understanding of medication, pharmacy, and delivery method, in collaboration with hospital/health plan/PCP discharge planning.
  7. Identifies primary care physician, specialists and case managers involved with patient’s plan of care; ensures transfer of needed clinical information to UCM.
  8. Ensures UCM virtual and in-person encounters are scheduled and ensures scheduled appointments take place.
  9. Maintains regular contact with patients and serves as UCM’s hub of coordination; serve as the patient’s advocate and program troubleshooter.
  10. Ensure UCM completes timely medical, behavioral health, social, and  ancillary support follow-up necessary for recovery.
  11. Provides clinical guidance to UCM Care Coordinators implementing follow-up clinical referrals; assists with communication of diagnostic testing results.
  12. Ensures timely flow of UCM documentation and information is sent to primary care medical group, specialists, and case manager(s) and maintains contact with PCP practices.
  13. Serves as liaison and advocate for case management of medical and social determinant of health needs.
  14. Communicates with the internal team and continually analyzes best practices and opportunities to avoid unnecessary return to the hospital.
  15. Adhere to all corporate Information Security policies and procedures.
  16. Identify any breaches or potential breaches of corporate Information Security standards and communicate those to appropriate individuals.
  17. Maintain integrity, availability, and confidentiality of all PHI.
  18. Adhere to HIPAA standards for information security, privacy, and confidentiality


Core Competencies: 

  1. Must have excellent verbal and written communication skills with patients/caregivers and all members of the healthcare team(s)
  2. Must be proactive in rapidly establishing rapport and quickly becoming an integral part of a tightly knit team
  3. Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes
  4. Highly organized and ability to work autonomously and ability to complete competing priorities
  5. Demonstrates a desire to promote a person-centered philosophy of care and seeks ways to facilitate helping more patients
  6. Excellent critical-thinking, observation, problem-solving, and analytical skills
  7. Ability to lead and motivate others to execute a plan in a rapidly changing environment
  8. Knowledge of hospital discharge planning, post-acute care needs and case management
  9. EHR proficient
  10. Current clinical license
  11. Valid driver's license and an insured vehicle in proper working order for local travel
  12. Behavioral health experience a plus
  13. Community liaison, marketing, sales, or admissions team experience a plus


  1. Current NYS unrestricted license or certification: RN or LPN, LMSW or LCSW, or EMT-P
  2. College degree



  • Minimum 2 years’ experience in a hospital, primary care office or homecare setting
  • Hospital Discharge planning/case management
  • Hands-on experience as part of an interdisciplinary team (physicians, case managers, nurses, etc.)
  • Deep understanding of factors leading to high/over utilization of ER and inpatient admissions such as complex medical and behavioral health care needs and social determinants of health
  • Proven track record in teamwork, collaboration and driving excellence in patient care

Physical Demands:

Occasional (0-40%) / Frequent (41-71%) / Constant (72%-100%)

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.

  • Constant computer work which may require repetitive motion, prolonged periods of sitting and sustained visual and mental applications and demands.
  • Occasional lifting, bending, pulling, collating, and filing, some of which could be heavy (>10lbs)


Travel: Only local travel is anticipated for this position (no overnight stays, etc.)

Other Duties:

This job description is intended to convey information essential to understand the scope of the position. It is not intended to be an exhaustive list of skills, efforts, duties, or responsibilities associated with the position. Duties, responsibilities, and activities may change at any time with or without notice.

Equal Employment Opportunity Statement:

UCM Digital Health maintains a strong policy of equal opportunity in employment. It is out objective to recruit, hire, and retain the most qualified individuals without regard to race, color, religion, sex, sexual orientation, or identity, national origin, age, disability, veteran status or any other characteristic or status protected by applicable federal, state or local law. Our equal employment philosophy applies to all aspects of employment, including recruitment, compensation, benefits, training, promotions, transfers, job benefits, and termination.

UCM Digital Health is an at-will employer. We recognize that you retain the option, as does the company, of ending your employment with UCM Digital Health at any time, with or without notice and with or without cause.