Acute Care Transitions Engagement Specialist

Direction Home Akron Canton Area Agency on Aging & Disabilities; Green (OH); On-site; USD 46,000 - 56,000; Full time

Job summary

Direction Home Akron Canton Area Agency on Aging & Disabilities seeks an Acute Care Transitions Engagement Specialist to support plans after acute or post-acute care. The role involves telephonic outreach, explaining services, and coordinating home or telehealth visits.

The position requires at least 1 year in customer service or related roles, strong MS Office skills, and excellent organizational abilities to drive scheduling and care coordination with program coaches.

Qualifications

• 1 year of experience in customer service, sales, administrative support, or a related role.
• Proficiency with Microsoft Office applications, including Outlook and Excel.
• Strong organizational, communication, and multi-tasking skills.

Responsibilities

• Organize daily workflows: manage censuses, logs, and zoning assignments for the Coaches.
• Telephonic outreach targets up to 50–60 calls daily and 60–80 chart reviews/facility outreaches.
• Update scheduling templates, calendars, and visit assignments across multiple platforms.
• Zone visits to minimize travel time and maintain workflow continuity.
• Use Excel to sort, filter, track, and prioritize censuses and visit needs.
• Enter and update member information and calls in the documentation platform.
• Verify admissions, discharges, transfers, and clinical status changes via HIE.
• Provide administrative support: documentation cleanup, call attempts tracking, census reconciliation.
• Escalate complex cases to Supervisors to promote engagement.

Skills

Customer service

Administrative support

Microsoft Office

Organizational skills

Communication skills

Multi-tasking

Education

High school diploma

At least 2 years college education

Tools

Microsoft Excel

Outlook

HIE platform

Job description

Job Details

Job Location: GREEN - UNIONTOWN, OH 44685, Position Type: Full Time, Salary Range: $46,000.00 - $55,500.00 Salary/year

Function

The Acute Care Transitions Engagement Specialist supports the Program in engaging members after acute care, post-acute facilities or emergency department encounter discharges. The role conducts timely outreach, explains program services, encourages participation, and schedules home or telehealth visits both during the facility stay and after the member has discharged. The Specialist also manages daily census reviews, platform documentation, member logs, zoning regions, scheduling workflows, and coordination with Program coaches and community partners to ensure timely transitional care.

JOB RESPONSIBILITIES

Organize daily workflows

• Maintain daily organization of incoming censuses, call logs and zoning assignments for the Program Coaches. Review daily MMO census and assign members to Coaches based on Risk Tier stratification, visit type, geography and productivity targets. Productivity targets may vary throughout the course of the Program and staffing fluctuations.
• This role is primarily telephonic for the course of the workday, in addition to research conducted via technological platforms (HIE research). Telephonic outreach targets may be up to 50-60 telephone calls to members daily, and 60-80 chart reviews/facility outreaches.
• Update scheduling templates, calendars and visit assignments across multiple platforms, utilizing resources to determine member demographics.
• Zone visits efficiently to minimize travel time and maximize Program productivity. Identify scheduling conflicts and cancellations and resolve them quickly to maintain workflow continuity.
• Use efficiencies with technical navigation and data review, navigate Excel spreadsheets to sort, filter, track and prioritize the daily censuses and visit needs.
• Enter and update member information and calls in the documentation platform with high accuracy and speed.
• Utilize the HIE to verify admissions, discharges, transfers and clinical status changes.
• Complete administrative support such as documentation cleanup, call attempts tracking, and census reconciliation.

Provide Program information & assistance

Communicate clearly with accurate presentation to encourage member enrollment onto the Program. Make daily effort to engage members onto the Program at the earliest available timeframe, ideally upon census notification, prior to discharge. Document all outreach efforts promptly. Maintain clean, organized scheduling records and ensure alignment across all platforms. Identify key clinical details (diagnoses, discharge summaries, SNF status, care needs) that impact scheduling decisions and pivot scheduling scripting accordingly. Communicate relevant clinical information to Nurse Coaches to support timely and appropriate outreach. Follow agency protocols within scope when relaying information or preparing coaches for visits. Maintain SNF outreach tracking, missed outreach follow‑up, and coordination of rescheduled visits. Communicate with post-acute staff when appropriate to promote member engagement. Escalate complex cases to Supervisors for troubleshooting, with goal of promoting engagement and decreasing member abrasion.

Perform any other job-related instructions as requested.

Qualifications

• High school diploma
• 1 year of experience in customer service, sales, administrative support, or a related role
• Optimal proficiency with Microsoft Office applications, including Outlook and Excel
• Strong organizational, communication, and multi-tasking skills

Preferred

• Experience in medical scheduling, care coordination, or clinical support roles.
• Background in healthcare, nursing support, or medical office operations.
• Familiarity with care management workflows or value‑based care programs.
• Experience working with multi‑provider or multi‑disciplinary teams.

At least 2 years college education