Job Description

Location: Steward Medical Group - North
Posted Date: 11/5/2021

Job Summary:
The position is a member of the Transitional Care Management team (TCM) who facilitates provider visits post facility discharge by telephone to assess the status of the patient. The purpose of each call is to obtain current health status, current medications, referral needs, and to schedule follow up appointments with their Primary Care provider to prevent readmission. Support includes, but is not limited to, making outbound initial and follow-up phone contacts, receiving return calls, gathering pertinent patient information and documenting in the medical record (Athena Clinicals) and scheduling post discharge provider visits directly into the EMR. (Athena Collector). The TCM Coordinator will escalate issues to the Director or Provider as warranted. Possibility to work remote after orientation if meeting productivity standards.


  • Receives information daily of all potential qualifying TCM patients by both an excel spreadsheet and by logging into the portal of an external vendor.
  • Sorts spreadsheet and uploads all qualifying patients to the TCM Dashboard. (SharePoint)
  • Direct outreach by telephone to all SMG patients being discharged from a qualifying facility or to home.
  • Obtaining and reviewing any discharge information given to the patient.
  • Establish referrals and arrange community resources that a patient can be involved in to regain daily living by informing provider.
  • Review the need for any follow-up diagnostic tests or treatment and inform practice.
  • Interact with other healthcare professionals involved in the patient’s aftercare, if necessary.
  • Provide education to the patient, family members and/or caregivers as needed and per providers.
  • Documents all telephone outreach into the medical record (Athena Clinicals)
  • Documents all activity on a TCM Outreach Dashboard. (SharePoint)
  • Obtains the information on the required TCM template and provides clear documentation for the provider.
  • Assist in scheduling any follow-up visits to the physician.
  • Reports significant observations and patient problems to appropriate care givers.
  • Participates in weekly TCM operation calls.


  • Minimum High School diploma or GED required.
  • College degree preferred.
  • Education from approved medical assistant program or equivalent.
  • 1 to 3 years of experience as a Medical Assistant
  • Medical terminology or basic medical knowledge.
  • Strong customer service background.
  • Experience with electronic medical record strongly preferred. (Athena a plus)
  • Experience with Microsoft Office, Word, Excel and Outlook.

Steward Health Care is the largest private, for-profit health care network in the United States. The company is owned and led by a management team of Steward physicians. Headquartered in Dallas, Texas, Steward employs more than 40,000 health care professionals and operates 35 hospitals across the United States and in the countries of Malta and Colombia which regularly receive top awards for quality and safety. The Steward network includes multiple urgent care centers and skilled nursing facilities, substantial behavioral health services, more than 7,000 beds under management, and approximately 2.2 million full risk covered lives through the company's managed care and health insurance services.

The Steward Health Care Network includes more than 5,000 physicians across 800 communities who help to provide more than 12 million patient encounters annually. Steward Medical Group, the company's employed physician group, provides more than six million patient encounters per year. The Steward Hospital Group operates hospitals in Malta, Colombia and nine states across the U.S., including Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, Texas, and Utah. For more information, visit

Steward Health Care is an Equal Employment Opportunity (EEO) employer, Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, and or expression or any other non-job-related characteristic.

Additional Information

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Steward Medical Group is taking additional necessary preparations to ensure patients can receive compassionate care in safe, carefully managed environment – with confidence and without fear.

Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience.

  1. Any COVID-19 related care takes place in designated areas away from other patients and their families.
  2. A stringent cleaning policy has been implemented throughout our facilities.
  3. A strictly controlled visitor and mask policy is required for patient and colleague safety.

Application Instructions

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