Transition of Care Associate

Summary

Interacts with patients/families to provide post-discharge transition of care outreach, linkage to care management resources, and care coordination in close collaboration with interdisciplinary team and colleagues across the continuum. Acts as an integral part of the care team and is responsible for conducting patient outreach (telephonic and may do in-person home visits) to foster engagement with new and current patients. Assists in application of evidence-based practice through ensuring closure of care gaps and preventive health outcomes. Responsible for meeting patients where they are within our physical/virtual walls and responsible for advanced level partnerships to support patients outside of the practice walls.

Job Duties

• Leads with the initial set-up and ongoing management of all post-discharge and care gap reports and assumes responsibility for ensuring all tracking systems are appropriately updated through documentation.
• Interacts with commercial payer groups, individuals, and leadership to drive effective clinical patient engagement strategies in conjunction with value-based contracting and quality initiatives.
• Collaborates with the nursing team to discuss patient engagement tactics and review barriers to ongoing care coordination, post-discharge appointment scheduling, and care gap closure.
• Organizes patient care activities and the sharing of information among all of the participants concerned with a patient's treatment to achieve more effective care including nursing team colleagues, ambulatory practices, and inpatient colleagues.
• Coordinates all patient engagement guidelines with the leads to ensure appropriate referral for ongoing CM services post-discharge.
• Creates and maintains quality data and spreadsheets for reporting and presentation purposes.
• Ensures sustainable client relationships of trust by thoughtfully responding to client inquiries regarding process or technical matters.
• Assists with the initial development of patient engagement and takes responsibility for maintaining all subsequent updates.

Minimum Qualifications

• High School Diploma/GED with required years of healthcare experience or Specialized Diploma Medical Assistant or related field
• 3 years experience working within a complex health system environment or Less than 1 year experience with Specialized Diploma
• Proficient in Microsoft Office applications.
• Analytical thinking.
• Ability to handle numerous tasks at the same time.
• Superior customer service skills.
• Working knowledge of basic computer functionality.
• Effective and professional written and verbal communication.
• Ability to maintain strict confidentiality.
• Ability to adapt to changing priorities
• Critical thinking skills and solution-focused approach.
• Knowledge of medical terminology.
• Knowledge and experience with electronic medical records and scheduling software.

Preferred Qualifications

• 5 years experience working within a complex health system environment
• Bilingual
• LPN - Licensed Practical Nurse_PA - State of Pennsylvania Upon Hire or CCMA - Certified Clinical Medical Assistant - National Healthcareer Association Upon Hire or CMA - Certified Medical Assistant - American Association of Medical Assistants Upon Hire or CMAC - Clinical Medical Assistant Certification - American Medical Certification Association Upon Hire or MAC - Medical Assistant Certification - American Medical Certification Association Upon Hire or NCMA - National Certified Medical Assistant - National Center for Competency Testing Upon Hire or NRCMA - National Registered Certified Medical Assistant - National Association for Health Professionals Upon Hire or RMA - Registered Medical Assistant - American Medical Technologists Upon Hire