Transition of Care Associate

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Perform outreach to patients and their families following discharge as part of the transition-of-care process.

• Connect patients with care-management resources and ensure coordination with interdisciplinary teams.

• Conduct outreach to patients via telephone and, when necessary, make in-person home visits.

• Encourage engagement among both new and existing patients.

• Address care gaps and enhance preventive health outcomes by utilizing evidence-based practices.

• Oversee the initial establishment and continuous management of reports related to post-discharge and care gaps.

• Keep tracking systems updated through thorough documentation.

• Collaborate with commercial payer groups, individuals, and leadership to promote clinical patient-engagement strategies.

• Work alongside nursing teams to develop engagement tactics, address care-coordination challenges, schedule appointments, and close care gaps.

• Facilitate the organization of patient-care activities and the sharing of information among nursing, ambulatory, and inpatient colleagues.

• Manage patient-engagement guidelines and referrals for continued case-management services post-discharge.

• Develop and sustain quality data and spreadsheets for reporting and presentation purposes.

• Address client inquiries related to processes or technical issues.

• Assist in the creation and ongoing updates of patient-engagement processes.

⛳️ Requirements

• High School Diploma/GED combined with the required years of healthcare experience or a Specialized Diploma in Medical Assistant or a related field.

• A minimum of 3 years of experience in a complex health system environment, or less than 1 year of experience with a Specialized Diploma.

• Proficient in Microsoft Office Suite.

• Strong analytical thinking abilities.

• Capacity to manage multiple tasks simultaneously.

• Exceptional customer service capabilities.

• Basic knowledge of computer operations.

• Effective written and verbal communication skills in a professional context.

• Ability to maintain strict confidentiality.

• Flexibility to adapt to shifting priorities.

• Strong critical thinking skills and a solution-oriented mindset.

• Familiarity with medical terminology.

• Experience with electronic medical records and scheduling software.

• Preferred: 5 years of experience in a complex health system environment.

• Preferred: Bilingual capabilities.

• Preferred certifications/licenses upon hire include LPN, CCMA, CMA, CMAC, MAC, NCMA, NRCMA, or RMA.

• Ability to lift and carry up to 25 lbs.; frequent sitting or standing and keyboard use; patient care providers may need to kneel, bend, squat, and perform CPR.

🏝️ Benefits

• Full-time employment.

• Day shift schedule.

• Monday to Friday work schedule with weekend rotation.