Transition of Care Associate

Lehigh Valley Hospital; United States; In loco; USD 40.000 - 60.000; Tempo pieno

Descrizione del lavoro

Lehigh Valley Health Network seeks a team-oriented professional to manage post-discharge outreach, link patients to care management resources, and coordinate across interdisciplinary teams. You will conduct telephonic and possible in-person visits to close care gaps and improve preventive health outcomes.

The role requires effective communication, confidentiality, and proficiency with EMR and scheduling software, working within a busy health system to support patients where they are located.

Competenze

• High School Diploma or GED required.
• Specialized Diploma in Medical Assistant or related field preferred.
• 3 years of healthcare experience in a complex health system preferred.
• Proficient in Microsoft Office applications.
• Analytical thinking and strong communication skills.
• Ability to manage multiple tasks and maintain confidentiality.
• Knowledge of medical terminology and EMR systems.

Mansioni

• Lead setup and maintenance of post-discharge and care gap reports.
• Coordinate with commercial payer groups and leadership to drive engagement and quality initiatives.
• Collaborate with nursing and ambulatory teams to review barriers to care coordination.
• Organize patient care activities and share information among care team members.
• Ensure referrals to care management services post-discharge.
• Create and maintain quality data and reports for presentation.
• Respond to client inquiries to sustain trusted relationships.
• Assist with development and updates of patient engagement processes.

Conoscenze

Analytical thinking

Customer service

Microsoft Office

Written and verbal communication

Confidentiality

Adaptability

Critical thinking

Medical terminology

EMR experience

Formazione

High School Diploma/GED

Specialized Diploma Medical Assistant

Strumenti

Microsoft Office

EMR systems

Scheduling software

Descrizione del lavoro

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 keybo