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Job Description

Job Title: Transition Care Coordinator
Job ID: 746787109
Status: Full-Time
Regular/Temporary: Regular
Hours: Daylight, M-F
Shift: Day Job
Facility: Univ. of Pgh Physicians
Department: 65869 POP18 PEDS Adolescent
Location: 3420 Fifth Avenue, Pittsburgh PA 15213


The outpatient Transition Care Coordinator (TCC) for the Division of Adolescent and Young Adult Medicine is responsible for coordination of interdisciplinary assessment, counseling, referral, and advocacy based on the needs of adolescents and young adults with complex health needs (AYA) as they transition from childhood to adulthood. Orient and educate staff, patients and families to the role of the TCC.

  • Orient and educate staff, patients and families to the role of the TCC.
  • Maintain extensive knowledge of federal, state and local assistance programs and community resources that affect patient needs; demonstrate expertise in accessing social systems by providing resource-specific information to patients/families, initiating contact with resources and facilitating the patient's / family's ability to accept referrals.
  • Monitor and evaluate the plan, options, and available services to effectively meet the patient's needs. Reassess the plan of care as status changes.
  • Foster peer support and community engagement for individual AYAs.
  • Performs duties and responsibilities in accordance with the philosophy and standards of UPMC, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers and external contacts.
  • Initiate and collaborate with the healthcare providers, patients and families, and relevant community resources to develop and implement an individualized interdisciplinary care plan.
  • Participate in Interdisciplinary Quality Improvement projects and Case Conferences.o As skills develop, expectations will include leadership roles in QI projects
  • Educate and advocate for patient and families to enhance their ability to make informed decisions regarding medical care.
  • Effectively coordinate the identification, assessment, and counseling of individuals who have medical and psychosocial complex needs.o A complete assessment includes social, economic, cultural, age/development related behavioral factors, history of child, elder or domestic abuse, prior psychiatric or substance abuse treatment, family and social support systems, and all other available resources.o Coordination of counseling includes communication with collocated, intra-system, and community-based therapists and professionals.
  • Demonstrate knowledge of reimbursement systems, the ability to train patient and families regarding payer requirements/coverage for outpatient services and individual's responsibilities regarding maintenance of health care coverage.
  • Provide accurate, timely and appropriate documentation of all social work care coordinated services the medical record per regulatory policies and procedures.
  • Participate in crisis assessment and utilize the modalities of crisis intervention, including brief goal-directed therapy or other therapeutic counseling methods.
  • Practice effective advocacy on behalf of patients to obtain authorization for services, while promoting the development of self-advocacy skills.
  • Provide follow-up and assess effectiveness of services after individuals have transferred from our clinical services.
  • Provide education to AYA regarding the case management process as indicated.


Masters degree in Social Work and at least one year experience working with vulnerable youth required

Licensure, Certifications, and Clearances:
  • Act 31 Child Abuse Reporting
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Salary Range: $19.47 to $31.85 / hour

    Union Position: No

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