Transitional Care Coordinator ED

Wyckoff Heights Medical Center

48d

About The Position

Perform screenings, education, and navigation for health-related social needs Document care coordination services and referrals in a timely and accurate manner, in the patient electronic health record (EHR) and any other platforms (e.g. Unite Us) as requested Assist patients with transportation needs to support timely and safe discharges and continuity of care at follow up appointments Coordinate/schedule follow up appointments for patients to support transition of care goals Conduct patient phone outreach post-discharge to support transitions of care Facilitate referrals of patients to Wyckoff programs that can support the patient’s treatment goals and/or social needs Provide support and facilitate access to resources to ED-based programs such as the Opioid Overdose Prevention Program Maintain a tracker of services provided and patients who were assisted, and provide regular reports and summaries as requested by supervisor and the 1115 Waiver leadership team Collaborate with other departments (e.g. Social Work, Population Health) to address patient needs holistically and comprehensively Demonstrate excellent customer service, professionalism, and sensitivity toward patients and coworkers Participate in regular huddles and interdisciplinary team meetings Attend trainings and orientations as required, including virtual, on-site and off-site Other related duties as assigned

Requirements

High School Diploma/GED

Nice To Haves

Experience working with electronic health records (EHRs) preferred.

Responsibilities

Perform screenings, education, and navigation for health-related social needs
Document care coordination services and referrals in a timely and accurate manner, in the patient electronic health record (EHR) and any other platforms (e.g. Unite Us) as requested
Assist patients with transportation needs to support timely and safe discharges and continuity of care at follow up appointments
Coordinate/schedule follow up appointments for patients to support transition of care goals
Conduct patient phone outreach post-discharge to support transitions of care
Facilitate referrals of patients to Wyckoff programs that can support the patient’s treatment goals and/or social needs
Provide support and facilitate access to resources to ED-based programs such as the Opioid Overdose Prevention Program
Maintain a tracker of services provided and patients who were assisted, and provide regular reports and summaries as requested by supervisor and the 1115 Waiver leadership team
Collaborate with other departments (e.g. Social Work, Population Health) to address patient needs holistically and comprehensively
Demonstrate excellent customer service, professionalism, and sensitivity toward patients and coworkers
Participate in regular huddles and interdisciplinary team meetings
Attend trainings and orientations as required, including virtual, on-site and off-site
Other related duties as assigned