Job DescriptionThe mission of the Transitional Care Coordination Program is to ensure intensive, coordinated, outpatient care for patients with complex chronic health problems that leave them medically vulnerable. Our vision is to address our patients' needs holistically; to improve health and well-being through coordinated medical services with emphasis on the social determinants that affect health such as housing, food and transportation.We do this by providing coordination and support for complex, vulnerable patients whose chronic health conditions and psychosocial challenges place them at high risk for repeated hospital admission or frequent returns to the emergency room. We prov