Transition of Care Associate

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

📋 Description

• Perform outreach for post-discharge transition-of-care, which may include telephonic communication and possible in-person home visits.

• Connect patients with care-management resources and collaborate with interdisciplinary teams to coordinate care.

• Promote engagement among both new and existing patients.

• Ensure the resolution of care gaps and achieve preventive health outcomes by utilizing evidence-based practices.

• Establish and oversee post-discharge and care-gap reporting.

• Maintain tracking systems through thorough documentation.

• Work in partnership with commercial payer groups, individuals, leadership, nursing teams, ambulatory practices, and inpatient colleagues.

• Address patient-engagement strategies and obstacles to effective care coordination.

• Manage scheduling of post-discharge appointments and the closure of care gaps.

• Organize patient-care activities and facilitate information sharing among treatment participants.

• Arrange referrals for ongoing care-management services following discharge.

• Develop and maintain quality data and spreadsheets for reporting purposes and presentations.

• Respond to client inquiries regarding processes or technical issues.

• Create and sustain patient-engagement processes and updates.

⛳️ Requirements

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

• Minimum of 3 years of experience in a complex health system environment, or under 1 year of experience with a Specialized Diploma.

• Proficient in Microsoft Office applications.

• Strong analytical thinking skills.

• Ability to manage multiple tasks simultaneously.

• Excellent customer service abilities.

• Basic knowledge of computer functionality.

• Effective and professional written and verbal communication skills.

• Capacity to maintain strict confidentiality.

• Flexibility to adapt to changing priorities.

• Critical thinking skills with a solution-focused mindset.

• Familiarity with medical terminology.

• Experience with electronic medical records and scheduling software.

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

• Preferred: Bilingual proficiency.

• Preferred: One of the listed LPN or medical assistant certifications upon hire.

• Ability to lift and carry 25 lbs.; frequent sitting/standing and keyboard usage; patient-care tasks may involve kneeling, bending, squatting, and performing CPR.

🏝️ Benefits

• Equal opportunity employment.

• Day shift schedule.

• Monday-Friday work week with weekend rotation; variable shifts and hours.