Care Transitions Navigator

Central Neighborhood Hlth Fdn; Valla (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Central Neighborhood Hlth Fdn is seeking a Transition of Care Management Coordinator to advocate for patients and coordinate post-acute care with PCPs. Based in Santa Fe Springs, CA, you will engage with hospital discharge teams, schedule follow-ups, reconcile medications, and monitor readmissions to improve outcomes.

Responsibilities include data collection, EHR documentation, and collaboration with clinics to ensure timely transitions and quality care for chronic patients.

Qualifications

• Proficient in medical terminology and documentation practices.
• Experience coordinating post-discharge activities and follow-ups.
• Strong communication with patients, families, and care teams.

Responsibilities

• Contact patients within 48 hours post-discharge to schedule PCP visits.
• Coordinate medication reconciliation and post-discharge care plans in the EHR.
• Arrange follow-up visits with PCPs or specialists within seven days.
• Refer to case managers and other resources as needed.
• Maintain data and prepare monthly dashboards for quality review.
• Ensure 24/7 access to clinical advice and support for members.

Skills

Medical Terminology

Appointment scheduling

Interpersonal communication

Customer service

Conflict resolution

Time management

Computer skills

Travel to clinics

Education

CPR certification

Job description

Central Neighborhood Hlth Fdn is seeking a Transition of Care Management Coordinator to advocate for patients and coordinate post-acute care with PCPs. Based in Santa Fe Springs, CA, you will engage with hospital discharge teams, schedule follow-ups, reconcile medications, and monitor readmissions to improve outcomes.

Responsibilities include data collection, EHR documentation, and collaboration with clinics to ensure timely transitions and quality care for chronic patients.