Transition of Care Specialist
This position will be responsible for assisting and facilitating, all patients and their families, a safe and timely transition of clients from inpatient care to alternative levels of care by acting as a patient advocate and navigator; provides support toward engagement in self-management goals to improve patients health, overcome barriers to care, and achieve value-based incentives by closing gaps while assisting patients over the phone.
Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism and competence.
OUR CORE VALUES
ESSENTIAL SKILLS AND EXPERIENCE
- Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and Red Cross (cognitive and skills evaluations)
- Demonstrated understanding of clinical methods and techniques used in record keeping systems.
- Detail oriented and demonstrated ability/creativity in critical thinking and problem solving. Ability to work independently, apply critical thinking skills when needed, multitask with ease, and demonstrate professionalism in all interactions of a high-stress and fast-moving environment.
- Minimum 2 years recent and related experience within healthcare, healthcare marketing, outreach and/or health education, health coaching and disease management experience required.
- Effective communication demonstrated by ability to read, interpret, comprehend, and comply with exceptional written and verbal communication skills and professional presence to communicate effectively with patients, co-workers, and the general population both in person and over the phone.
- Demonstrated ability in implementing the principles and practices of supervision.
- Demonstrated empathy, compassion and listening skills
- Ability to multi-task and work effectively in a high-stress and fast-moving environment
- Previous call center experience strongly preferred
- Advanced computer efficiency in Microsoft Office suite (Word, Excel, PowerPoint, Outlook) and experience in Electronic Healthcare Records (EMR)
- Meet the organization immunization requirement
- 2 or more years experience in a clinical setting
- High school diploma or GED from an accredited institution
- Graduation from an accredited medical assistant program, certification highly preferred.
- Bilingual (Spanish/English)
NONESSENTIAL SKILLS AND EXPERIENCE
- Experience with patient education and advocacy
- Medical Assistant Certification
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job related selection or promotional criteria.
- Participates in Clinical Outcomes team meetings and quality improvement initiatives, staff meetings, in-service meetings, or other required meetings
- Coordinates continuity of patient care with external healthcare organizations and facilities such as referrals to outside specialties; ongoing two way communication between providers.
- Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting. Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.
- Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan. Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.
- Assist and support patients and families in making appropriate arrangements for the post-acute plan. Performs follow-up calls to patients and providers as indicated and report any concerns to leadership.
- Develops relationships with external healthcare organizations and facilities in efforts to finding additional resources.
- Motivates patients to be active, engaged participants in their health. Helps manage high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including data entry/management.
- Helps manage high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including data entry/management.
- Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.
- Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans and collaborates with all members of the healthcare team to implement, manage, and communicate the transition of care arrangements.
- Facilitates patient care based upon standing orders and protocols.
- Works collaboratively with Clinical Informatics team for data collection, health outcomes reporting, clinical audits and programmatic evaluation.
- Helps evaluate clinical care, utilization of resources and development of new clinical tools, forms and procedures.
- Manage documentation requests and scheduling of document exchange
- Excellent customer service and communication skills
- Will perform high volume of daily patient outreach calls while still attending incoming calls.
- Ensure patient needs and requests are handled efficiently by performing telephonic patient scheduling of patient initial and follow up appointments.
- Perform patient pre-registration including accessing and updating patient information as indicated
- Perform data entry
- Maintain schedule accuracy for maximum patient flow
- Follow established procedures for answering and screening incoming appointment-related telephone calls, scheduling interpreters, and directing calls to appropriate staff
- Maintains good attendance, is punctual and works full scheduled shift
Additional Duties and Responsibilities
- Other duties as request or assigned
All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team based model to promote wellness and improve health outcomes.
Adherence to Compliance and Code of Conduct
All employees are required to comply with Adelante Healthcares written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelantes legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance, and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
Work environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic areas.
In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630, if the essential functions of this position cannot be performed in a satisfactory manner by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization.