Care Transitions Specialist II

Jewish Association for Services for the Aged • New York, NY

6d

About The Position

The Care Transitions Specialist II plays a frontline role in JASA’s Medication Adherence Program, connecting clinical healthcare with community-based support for older adults managing chronic conditions. The position uses structured telephone outreach and in-home visits across New York City to assess medication-adherence barriers, provide chronic disease education, and coordinate with healthcare providers and health plans so members can follow medication plans safely. The role calls for strong clinical communication, empathy, and cultural competence, including attention to social determinants of health, pharmacy coordination, and members’ long-term wellness and independence.

The position is based at 247 West 37th Street, New York, New York 10018, with travel throughout NYC for home assessments. The stated schedule is Monday through Friday, 9:00 AM to 5:00 PM.

Requirements

• International Medical Graduate (IMG) or equivalent healthcare professional.
• Bilingual fluency in English and Spanish, written and verbal.
• Ability to travel throughout New York City via public transportation for home assessments.
• Ability to independently negotiate physical stairs and environmental barriers within residences.
• Strong working knowledge of diabetes, hypertension, hyperlipidemia, pharmacology basics, medication management, and chronic disease self-management.
• Strong telephone engagement and motivational interviewing skills.
• Ability to communicate professionally with physicians, pharmacists, and health plan representatives.
• Computer proficiency, including Microsoft Office Suite (Word, Excel, Outlook), and experience navigating EHR systems and health data platforms.
• Understanding of and appreciation for 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.
• 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 deliver medication-adherence interventions.
• Educate members about 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-effect concerns, 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.
• Evaluate social needs and connect members with community resources, food assistance programs, and supportive social services.
• Document encounters, home assessments, and progress milestones 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

• Choice of three medical 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.
• Professional development opportunities, including learning, clinical case conferences, and healthcare career growth.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed