• Hospital Discharge Coordinator - NP/PA

    Job Locations US-CA-Hayward
    Job ID
    Location Site
    Clinical Services
    Regular Full-Time
  • Overview

    Tiburcio Vasquez Health Center (TVHC) is a leading nonprofit community health center that has provided comprehensive medical, dental, and mental health care since 1971 that primarily serves the community's underserved population. TVHC is located in Hayward, California and is part of the beautiful San Francisco East Bay area.


    The  Care Transitions Coordinator NP/PA is part of a patient-centered team who delivers culturally sensitive appropriate care to patients in transition between the hospital and primary care setting. The Care Transitions Coordinator works in a collaborative effort across all TVHC departments to remove barriers for accessing healthcare services. The Primary responsibility includes providing outpatient care to patients who have been discharged from the hospital or emergency room setting, and patient education and advocacy. In addition, this position communicates with hospital and health plan based care teams to coordinate patient transitions between levels of care. Under the general direction of the Senior Director of Population Health, and in consultation with the CMO and COO, performs Nurse Practitioner/PA care, including health assessments, thorough history and physical examination, ordering or performing certain diagnostic tests, medication reconciliation and orders, psychosocial evaluations, and any necessary follow up care.  The Care Transition Coordinator may oversee clinical care as compatible with their licensure including monitoring of duties performed by LVN and MA staff, and provide administrative oversight to the Care Transitions Patient Navigator and Community Health Worker.



    • Monday through Friday
    • 100% Medical expspenses covered (includes no co-pays). Spouse and dependent coverage also available.
    • Dental, vision (spouse and dependent coverage available)
    • Generous PTO
    • 14 holidays
    • Flexible Spending Accounts
    • 403(b) retirement savings plan


    • Provides outpatient care to patients recently discharged from the hospital.
    • Maintains accurate tracking list of TVHC hospitalized patients from all local hospitals
    • Maintains access to the established list of high risk patients through health plan portal or other confidential site.

    • Communicate clearly with TVHC patients about care plans.
    • Ensure timely and appropriate hospital follow up and medical appointments.
    • Notify TVHC staff as appropriate when patients are admitted to local hospitals.
    • Review hospital discharge plan and notify primary care providers of important medical and social issues during hospitalization.
    • Provides administrative oversight and supervision to Care Transitions Patient Navigator and Community Health Worker.
    • Coordinate with COO, CMO, Quality Improvement team and Population Health Director to organize, track, and report data.
    • Represent TVHC in Care Transitions work group meetings with outside agencies.
    • Provide quarterly statistics report to Sutter staff for all Care Transitions programs.
    • Supports TVHC staff located at Eden Hospital, and aid staff in effective communication with hospital staff and patients.
    • Provide referrals for TVHC patients who qualify for additional home health services after hospitalization to include TVHC and community programs.
    • Provides nursing services including: administration of medication and injections to patients as directed by the provider; immunizations; referrals to other providers and community health resources; and health instruction to patients or following examinations.
    • Performs encounter forms and completes super bills for appropriate clinical visits.
    • Documents patient’s current medication list, including name(s) of meds, dosages, frequency, duration and start date. Compare transfer order to previous hospital orders.
    • In the capacity of patient advocate, assesses the learning needs of patients, develops and implements patients’ education as appropriate; acts as a resource and contact person for hospital patients.
    • Performs all duties and services in full compliance of TVHC’s Service Excellent Standards.
    • Performs all duties necessary for successful EHR/EPM entries and maintenance of patient/client records. Performs other related duties as may be assigned by Senior Director of Population Health, COO and/or CMO.


    • Graduation from a certified Nurse Practitioner or related program, which entails trainings as well as practice in the above, mentioned duties.
    • Previous experience providing medical care in a community health center environment preferred.


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