Transition of Care Associate

Lehigh Valley Health Network • REMOTE IN PENNSYLVANIA, PA

1d • Remote

About The Position

The Transition of Care Associate interacts with patients and families to provide post-discharge transition-of-care outreach, connect patients with care management resources, and coordinate care in collaboration with an interdisciplinary team and colleagues across the continuum. The associate is an integral part of the care team and conducts patient outreach by telephone and may conduct in-person home visits to foster engagement with new and current patients. The role supports evidence-based practice by helping close care gaps and improve preventive health outcomes, meeting patients within physical or virtual settings, and developing partnerships to support patients beyond the practice setting.

The associate manages post-discharge and care-gap reports and tracking documentation, works with payer groups and organizational leaders on patient-engagement strategies, and collaborates with nursing and other care-team colleagues on coordination barriers, appointment scheduling, and care-gap closure. The role also coordinates referrals for ongoing case-management services, maintains quality data and spreadsheets, responds to client inquiries, and helps develop and maintain patient-engagement processes.

Requirements

• High school diploma/GED with the required years of healthcare experience, or a specialized diploma in Medical Assisting or a related field.
• Three years of experience working within a complex health system environment, or less than one year of experience with a specialized diploma.
• Proficiency in Microsoft Office applications.
• Analytical thinking skills.
• Ability to handle multiple tasks at the same time.
• Superior customer service skills.
• Working knowledge of basic computer functionality.
• Effective and professional written and verbal communication skills.
• Ability to maintain strict confidentiality.
• Ability to adapt to changing priorities.
• Critical-thinking skills and a solution-focused approach.
• Knowledge of medical terminology.
• Knowledge and experience with electronic medical records and scheduling software.

Nice To Haves

• Five years of experience working within a complex health system environment.
• Bilingual ability.
• Upon-hire qualification as one of the following: Pennsylvania Licensed Practical Nurse (LPN); Certified Clinical Medical Assistant (CCMA) from the National Healthcareer Association; Certified Medical Assistant (CMA) from the American Association of Medical Assistants; Clinical Medical Assistant Certification (CMAC) from the American Medical Certification Association; Medical Assistant Certification (MAC) from the American Medical Certification Association; National Certified Medical Assistant (NCMA) from the National Center for Competency Testing; National Registered Certified Medical Assistant (NRCMA) from the National Association for Health Professionals; or Registered Medical Assistant (RMA) from American Medical Technologists.

Responsibilities

• Lead initial setup and ongoing management of post-discharge and care-gap reports, ensuring tracking systems are updated through documentation.
• Work with commercial payer groups, individuals, and leadership to support patient-engagement strategies connected to value-based contracting and quality initiatives.
• Collaborate with the nursing team to discuss patient-engagement approaches and barriers to care coordination, post-discharge appointment scheduling, and care-gap closure.
• Organize patient-care activities and information sharing among nursing colleagues, ambulatory practices, inpatient colleagues, and other participants in a patient's treatment.
• Coordinate patient-engagement guidelines with leads to ensure appropriate referral for ongoing case-management services after discharge.
• Create and maintain quality data and spreadsheets for reporting and presentations.
• Respond thoughtfully to client inquiries about processes or technical matters to sustain relationships of trust.
• Assist with developing patient-engagement processes and maintain subsequent updates.
• Conduct patient outreach by telephone and potentially through in-person home visits.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED