Transitions of Care Specialist

APLA Health•Long Beach, CA

2d•$26 - $30•Onsite

About The Position

Transitions of Care Specialist is responsible for optimizing transitions of care processes for APLA Health patients transitioning from an emergency department (ED) or hospital back to the clinic.

Requirements

Bachelor's Degree; or AA degree and 2 years work experience in health care, or health education.
Minimum 1 year experience working in a healthcare setting with people who have health conditions impacting their lives.
Experience working in a clinical environment.
Experience in working with culturally diverse communities with the ability to be culturally sensitive and appropriate, namely with the LGBT and other underserved communities.
Strong interpersonal skills and the ability to relate to individuals who may not share basic commonalities, including value systems and behavior norms.
Ability to provide service to individuals with diverse economic, social, racial, and cultural backgrounds.
Good written and verbal communication skills, including ability to communicate effectively and with patients and family members who speak English as a second language.
Experience working with an electronic health record (eCW preferred).
Proficiency with Microsoft Office: Word, Excel and PowerPoint.
Ability to multi-task and work quickly with minimal errors.
Commitment to teamwork and collaboration.
Highly enthusiastic and confident communication style capable of motivating others.
Bilingual in Spanish required.
Knowledge of local community resources, health and social service systems in the local community, and skill in establishing working relationships with community partners with appropriate support.
Ability to establish and maintain personal and programmatic boundaries while providing supportive services.
Serve with minimal supervision.
Ask probing questions, understand concerns and exercise good judgment to handle calls properly.
Ensure patient confidentiality and high-quality customer service at all times.
Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.
COVID-19 and Booster or Medical/ Religious Exemption required.

Responsibilities

Work in conjunction with the quality department, medical directors and clinic directors to develop and implement strategies to optimize the processes for patients transitioning care from emergency departments and hospitals back to the clinic; and facilitate timely prepartum and postpartum care for pregnant patients, in accordance with key quality measure parameters.
Develop processes to obtain the most timely and complete data possible regarding APLA Health’s patients receiving care in emergency departments and hospitals. Sources of data may include health information exchanges, such as LANES, health system portals, Managed Care Plan/Independent Physician Associations portals (MedPoint Manangement or Cozeva) or direct communication from IPAs (patient discharge PDC reports).
Track patients who have been admitted to a hospital or visited an emergency department, and maintain accurate records on linking patients back to their primary care team at APLA Health. Communication with the responsible APLA Health care team will ensure the care team is aware of the patient and the TOC Specialist will continue to monitor the process until each patient has been triaged.
The TOC Specialist will obtain records of the ED or hospital visit and upload them to the patients’ charts as soon as possible. They will schedule follow up appointments for the transitioning patients according to the instructions of the care teams.
Work in conjunction with the enrollment team for eligibility checks for newly assigned patients, particularly those identified through ED or ER notifications but not yet seen, and ensure they can be promptly be followed up by a PCP at the CHC.
May coordinate resources to improve patient ability to adhere to appointments, including assistance with transportation.
May screen patients for social needs and help link patients to APLA Health or community resources to address identified needs.
May work with care teams at all APLA Health medical clinics to optimize local community resource guides to be used to help link transitioning patients to the most appropriate local community resources.
Monitor and report IPA data related to ED/Hospital discharges and prepartum/postpartum care to ensure accuracy of data and to ensure that patients are receiving timely follow up to meet key quality measure goals.
Monitor and report IPA data on ED and hospital readmissions and coordinate with care teams to ensure such patients are linked to medical care and social needs resources as needed.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.