Transition of Care Specialist - Emergency Department

Rural Health Group•Roanoke Rapids, NC

27d•Onsite

About The Position

Rural Health Group at our Halifax Medical Specialists location is seeking a compassionate, organized, and motivated Transition of Care Specialist to play a key role in connecting patients back to care and supporting our value-based care efforts. The Transition of Care (TOC) Specialist – Emergency Department helps patients safely transition from the Emergency Department back to primary care. Through timely outreach and care coordination, this role helps patients understand their discharge plan, access follow-up care, address barriers, and reduce avoidable Emergency Department visits.

Requirements

High school diploma or equivalent required.
Valid driver's license and reliable transportation.

Nice To Haves

One or more years of experience in care coordination, case management, population health, ambulatory care, or a healthcare setting preferred.
Strong communication and patient engagement skills.
Ability to build trusting relationships with patients.
Knowledge of care coordination principles and community resources.
Strong organizational and time management skills.
Experience using electronic health records and Microsoft Office applications preferred.

Responsibilities

Review daily Emergency Department reports to identify patients requiring follow up.
Contact patients after an Emergency Department visit within established timeframes.
Assess patient needs, review discharge instructions, and reinforce the importance of follow-up care.
Schedule follow-up appointments with the patient's primary care provider or appropriate clinical services.
Identify barriers that may prevent patients from completing recommended follow-up care.
Coordinate services with providers, hospitals, specialists, and other members of the care team.
Connect patients with appropriate resources to support a successful recovery.
Refer patients with ongoing medical, behavioral, or social needs to the appropriate internal team, including Community Health Workers/Case Managers or Population Health.
Educate patients on appropriate use of primary care, urgent care, and Emergency Department services.
Encourage medication adherence and participation in recommended treatment plans.
Support patients in navigating the healthcare system and understanding their care plan.
Monitor assigned patient caseloads to ensure timely follow-up.
Identify trends and barriers impacting Emergency Department utilization.
Participate in initiatives that improve care transitions and patient outcomes.