Transitional Care Specialist - Houston

VillageMD • Houston, TX

291d

About The Position

At VillageMD, we're looking for a Transitional Care Specialists to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results. We're creating care that's more accessible, effective, and efficient. With solutions that are value-based, physician-driven, and patient-centered. To accomplish this, we're looking for individuals who share our sense of excellence, are ready to embrace change, and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning. Integral to our Care Management team, the Transitional Care Specialists is accountable for collaborating with the care team to consistently communicate and document high risk patient profiles to provider and practice care teams. As a new member of VillageMD, you'll work closely with our multidisciplinary care team to connect the dots of collaborative patient care while incorporating patients' personal health and lifestyle goals.

Requirements

• 3+ years of experience in a medical office or health care setting
• Comfort with technology including the Microsoft suite of products
• Prior experience using electronic health record including data capture, data mining and reporting

Nice To Haves

• Achieving objectives by effectively managing multiple tasks at one time
• Maintaining an organized and systematic workflow that results in goals being met
• Flexibility in an ambiguous and dynamic environment, maintaining a positive and 'can do' attitude
• A passion for changing the way healthcare is experienced for complex and/or disadvantaged patients and communities
• Demonstrated strength-based approach to collaborative problem solving
• Effective engagement of diverse populations (age, ethnic groups, socio-economic levels, etc.) with exhibited cultural sensitivity
• A willingness to learn on your own and take initiative
• Demonstrated honesty and following through on commitments
• The ability to problem-solve on the spot and identify issues that need escalated
• A low ego and humility; an ability to gain trust through good communication

Responsibilities

• Outreach and engage patients whom are high risk, post-discharge, and/or requiring additional care management support, ensuring they have Primary Care Provider (PCP) follow up appointments scheduled and all care gaps are closed
• Collaborate with care team members and external vendors to support patient care (ie: receipt of durable medical equipment (DME) and home health services)
• Request medical records from a variety of physicians and healthcare systems enabling the continuity of care for both PCPs and members of the interdisciplinary care team
• Outreach, screen and escalate patients to nursing and social work team members based on the unique needs of patients
• Assist nursing and social work team members with patient follow up, providing tools and resources at their direction
• Monitor stable patient populations at the direction of nursing and social work team members
• Address open care gaps with patients through collaborative relationships with patients, ensuring supporting adequate documentation is available with the patient's medical record
• Coordinate with local community resources as needed to support both the physical and psychosocial needs of patients
• Collaborate with multi-disciplinary team members to provide best in class patient care and improved outcomes
• Participate in special initiatives at the direction of market leaders

Benefits

• Medical, Dental, Life, Disability, Vision, FSA coverages
• 401k savings plan

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services