Transition of Care Associate

1004 Lehigh Valley Hospital; Pennsylvania; Hybrid; USD 52,000 - 76,000; Full time

Job summary

Lehigh Valley Health Network seeks a care coordination specialist to engage patients after discharge, close care gaps, and coordinate with care teams. You will manage post-discharge reports, collaborate with payers and leadership, and help schedule follow-ups to improve preventive health outcomes.

Remote in Pennsylvania with Day shifts; the role emphasizes strong communication, confidentiality, and use of EMR and scheduling tools to support seamless patient care transitions.

Qualifications

• High School Diploma/GED with required years of healthcare experience or Specialized Diploma Medical Assistant or related field.
• 3 years experience working within a complex health system environment or Less than 1 year experience with Specialized Diploma.
• Proficient in Microsoft Office applications.
• Analytical thinking.
• Ability to handle numerous tasks at the same time.
• Superior customer service skills.
• Working knowledge of basic computer functionality.
• Effective and professional written and verbal communication.
• Ability to maintain strict confidentiality.
• Ability to adapt to changing priorities
• Critical thinking skills and solution-focused approach.
• Knowledge of medical terminology.
• Knowledge and experience with electronic medical records and scheduling software.

Responsibilities

• Leads with the initial set-up and ongoing management of post-discharge and care gap reports and ensures tracking systems are updated.
• Collaborates with payer groups, individuals, and leadership to drive patient engagement strategies in value-based care and quality initiatives.
• Discusses patient engagement tactics with the nursing team and coordinates follow-up scheduling to close care gaps.
• Organizes patient care activities and information flow among care team members to improve outcomes.
• Maintains quality data and reporting for presentations and ensures referrals for CM services post-discharge.

Skills

Analytical thinking

Superior customer service

Written and verbal communication

Confidentiality

Microsoft Office

Multi-tasking

EMR systems knowledge

Education

High School Diploma/GED

Tools

Electronic Medical Records (EMR)

Scheduling software

Job description

Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day. Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Interacts with patients/families to provide post-discharge transition of care outreach, linkage to care management resources, and care coordination in close collaboration with interdisciplinary team and colleagues across the continuum. Acts as an integral part of the care team and is responsible for conducting patient outreach (telephonic and may do in-person home visits) to foster engagement with new and current patients. Assists in application of evidence-based practice through ensuring closure of care gaps and preventive health outcomes. Responsible for meeting patients where they are within our physical/virtual walls and responsible for advanced level partnerships to support patients outside of the practice walls.

Job Duties

Leads with the initial set-up and ongoing management of all post-discharge and care gap reports and assumes responsibility for ensuring all tracking systems are appropriately updated through documentation. Interacts with commercial payer groups, individuals, and leadership to drive effective clinical patient engagement strategies in conjunction with value-based contracting and quality initiatives. Collaborates with the nursing team to discuss patient engagement tactics and review barriers to ongoing care coordination, post-discharge appointment scheduling and care gap closure. Organizes patient care activities and the sharing of information among all of the participants concerned with a patient's treatment to achieve more effective care including nursing team colleagues, ambulatory practices, and inpatient colleagues. Coordinates all patient engagement guidelines with the leads to ensure appropriate referral for ongoing CM services post-discharge. Creates and maintains quality data and spreadsheets for reporting and presentation purposes. Ensures sustainable client relationships of trust by thoughtfully responding to client inquiries regarding process or technical matters. Assists with the initial development of patient engagement and takes responsibility for maintaining all subsequent updates.

Minimum Qualifications

• High School Diploma/GED with required years of healthcare experience or Specialized Diploma Medical Assistant or related field
• 3 years experience working within a complex health system environment or
• Less than 1 year experience with Specialized Diploma
• Proficient in Microsoft Office applications.
• Analytical thinking.
• Ability to handle numerous tasks at the same time.
• Superior customer service skills.
• Working knowledge of basic computer functionality.
• Effective and professional written and verbal communication.
• Ability to maintain strict confidentiality.
• Ability to adapt to changing priorities
• Critical thinking skills and solution-focused approach.
• Knowledge of medical terminology.
• Knowledge and experience with electronic medical records and scheduling software.

Preferred Qualifications

• 5 years experience working within a complex health system environment
• Bilingual
• LPN - Licensed Practical Nurse_PA - State of Pennsylvania Upon Hire or
• CCMA - Certified Clinical Medical Assistant - National Healthcareer Association Upon Hire or
• CMA - Certified Medical Assistant - American Association of Medical Assistants Upon Hire or
• CMAC - Clinical Medical Assistant Certification - American Medical Certification Association Upon Hire or
• MAC - Medical Assistant Certification - American Medical Certification Association Upon Hire or
• NCMA - National Certified Medical Assistant - National Center for Competency Testing Upon Hire or
• NRCMA - National Registered Certified Medical Assistant - National Association for Health Professionals Upon Hire or
• RMA - Registered Medical Assistant - American Medical Technologists Upon Hire

Physical Demands

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Disclaimer

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Equal Opportunity

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

Agency Policy

Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

Location and Work Schedule

Work Shift: Day Shift

Address: 1200 S Cedar Crest Blvd

Primary Location: REMOTE IN PENNSYLVANIA

Position Type: Remote Union: Not Applicable Work Schedule: Monday-Friday; 8:00a-4:30p with weekend rotation Department: 1004-13010 COH-Payor Based Care Coordination

About LVHN

Lehigh Valley Health Network (LVHN) is the region’s largest employer and health care provider of choice. Our nearly 20,000 health care professionals take pride in what they do and are driven by our mission to heal, comfort and care for the people of our community. https://youtu.be/GD67a9hIXUY LVHN is honored to be certified as a Great Place to Work®. LVHN’s culture of trust – and the positive things colleagues said about working at LVHN when surveyed by Great Place to Work and Fortune – align perfectly with what makes a great workplace. This designation tells you that LVHN is a great place to work from hire to retire. If you are someone who aligns with LVHN’s core values – Compassion, Integrity, Collaboration and Excellence – you will have a rewarding and successful career here.