Care Transitions Specialist II
About The Position
The Care Transition Specialist II works in JASA’s Medication Adherence Program, serving as a frontline link between clinical healthcare and community-based support for older adults managing chronic conditions. Through structured telephone outreach and in-home visits across New York City, the specialist assesses medication-adherence barriers, provides chronic-disease education, and coordinates with healthcare providers and health plans to help members follow medication plans safely. The role emphasizes clinical communication, empathy, cultural competence, attention to social determinants of health, pharmacy coordination, and support for members’ long-term wellness and independence. The position is based at 247 West 37th Street in New York City. The stated schedule is Monday through Friday, 9:00 AM to 5:00 PM, and work includes travel throughout NYC for home assessments. The posting’s main description also refers to this position as the Medication Adherence Care Specialist.
Requirements
- International Medical Graduate (IMG) or equivalent healthcare professional.
- Bilingual fluency in English and Spanish, written and verbal, is required.
- Strong working knowledge of diabetes, hypertension, hyperlipidemia, pharmacology basics, medication management, and chronic-disease self-management.
- Ability to travel throughout New York City via public transportation to conduct home assessments.
- Ability to independently negotiate physical stairs and environmental barriers in residences.
- Strong telephone engagement and motivational interviewing skills.
- Ability to communicate professionally with physicians, pharmacists, and health plan representatives.
- Computer proficiency, including Microsoft Word, Excel, and Outlook.
- Experience navigating Electronic Health Record (EHR) systems and health data platforms.
- Cultural competence and understanding of how race, religion, ethnicity, sexual orientation, and individual values shape healthcare choices and community care.
Nice To Haves
- Clinical background in medicine, nursing, pharmacy, public health, or care management is strongly preferred.
- Familiarity with Medicare, Medicaid, managed long-term care (MLTC), and community resources.
Responsibilities
- Conduct outbound telephone outreach and in-home visits across NYC to assess physical needs, evaluate living environments, and provide medication-adherence interventions.
- Educate members about chronic-disease self-management and medication adherence, with a focus on diabetes, hypertension (including RAS antagonists), and hyperlipidemia (statin therapy).
- Identify and address adherence barriers, including medication affordability, transportation gaps, side effects, health literacy, and access to prescribers.
- Coordinate with physicians, pharmacies, caregivers, and health plan partners on prescription renewals, refills, 90-day supply conversions, medication synchronization, and prior authorizations.
- Assess social needs and connect members with community resources, food assistance, and supportive social services.
- Document encounters, home assessments, and progress in EHR platforms and program databases in compliance with HIPAA and regulatory standards.
- Participate in case conferences, quality improvement initiatives, and interdisciplinary team meetings.
- Promptly escalate urgent clinical or safety concerns to clinical supervisors.
Benefits
- Medical coverage with a choice of three plans, dental coverage, and vision coverage at low cost.
- Employee Wellness Programs and an Employee Assistance Program (EAP).
- 403(b) retirement plan with Roth option and an employer-funded pension.
- Four weeks of vacation, plus holidays, floating holidays, and sick days.
- Opportunities for learning, clinical case conferences, and healthcare career growth.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
