Transition of Care Associate
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 interdisciplinary teams and colleagues across the continuum. The role is an integral part of the care team and conducts outreach by telephone and may conduct in-person home visits to encourage engagement with new and existing patients. It supports evidence-based practice by helping close care gaps and improve preventive health outcomes, meeting patients within physical or virtual settings and partnering to support them beyond practice settings. The associate manages post-discharge and care-gap tracking and reporting, supports patient engagement strategies in coordination with payer groups and organizational quality initiatives, and collaborates with nursing and other care-team colleagues to address barriers to care coordination and follow-up. The position is remote in Pennsylvania, with a day shift schedule of Monday through Friday, 8:00 a.m. to 4:30 p.m., including a weekend rotation and variable shifts and hours.
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 numerous tasks simultaneously.
- 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.
- Upon hire, one of the following credentials: LPN (Licensed Practical Nurse, Pennsylvania); CCMA (Certified Clinical Medical Assistant, National Healthcareer Association); CMA (Certified Medical Assistant, American Association of Medical Assistants); CMAC (Clinical Medical Assistant Certification, American Medical Certification Association); MAC (Medical Assistant Certification, American Medical Certification Association); NCMA (National Certified Medical Assistant, National Center for Competency Testing); NRCMA (National Registered Certified Medical Assistant, National Association for Health Professionals); or RMA (Registered Medical Assistant, American Medical Technologists).
Responsibilities
- Lead the 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 advance clinical patient-engagement strategies connected to value-based contracting and quality initiatives.
- Collaborate with the nursing team on patient-engagement tactics 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 on process or technical matters to maintain trusted client relationships.
- Assist with the initial development of patient engagement and maintain subsequent updates.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
