Transition of Care Partner
About The Position
The Transitional Care Partner provides preventative care and outreach for varying at risk populations. Facilitates follow-up for patients who have had a recent discharge, including but not limited to: inpatient hospital discharges, emergency room visits, postpartum units, skilled nursing and rehabilitation facilities. They are responsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resources. Provides care coordination and support to clients overcoming barriers with chronic medical and behavioral health that are also impacted by social determinants of health. Provide optimal care through differing EMR systems and healthcare platforms.
Requirements
- HS Diploma
- 1 year of relevant experience
Responsibilities
- Facilitates bidirectional information exchange with hospital and primary care provider/team
- Performs rounds to hospital where indicated to meet with patients, admission personnel, case managers, discharge planners, others
- Performs outreach follow-up for patients who have had a recent discharge, including but not limited to: inpatient hospital discharges, emergency room visits, postpartum units, skilled nursing and rehabilitation facilities
- Responsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resources
- Obtain hospital records and ensures records are received (scanned/e-faxed) in eCw. Identifies barriers to interdisciplinary collaboration and proposes strategies to improve TOC
- Identifies needed follow-up on tests or and indicates via appropriate EMR documentation
- Coordinates patient documentation such as hospital discharge papers, medication lists, and visit summaries, that will prepare the patient for the healthcare provider visit. Obtains consultant reports, medical record releases and consents
- Accountable for managing an outreach schedule for patient follow-up and appointment setting, while providing care coordination with both internal and external stakeholders
- Evaluates and assists patient with overcoming barriers to obtaining necessary appointments and medical care
- Screens patients for factors influencing social determinants of health and initiates referrals using appropriate resources
- Consults with transition of care team and seeks clarification when needed; identifies and escalates encounters that require complex care or medical triage
- Participates in development and implementation of patients Transition of Care Plan, coordinating with nursing, to meet established goals
- Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff
- Monitor and coordinates treatment plans as indicated by licensed clinical personnel
- Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
1,001-5,000 employees
