1. Assessment Triage member to identify medical, psychological, and social barriers to discharge then transition member to appropriate healthcare professional on their team such as TCN or CHW. 2. Care Transition Collaboration Work with healthcare team to ensure safe and smooth member transitions 3. Education Inform members and families about appointments and other care plan requirements. 4. Follow-Up Coordination Schedule and monitor follow-up appointments with providers and community services. 5. Post-Discharge Follow-Up Track member progress and address needs through calls following call cadence Refers to TCN for medical needs and CHW for community needs. 6. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid
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Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree