Care Transition Specialist

1 month ago

Ithaca, United States Cayuga Health System Full time
Job DescriptionJob Description

Cayuga Health and its affiliates are the region's leading healthcare system and most trusted providers of integrated health services, empowering our people in our mission to equitably improve the well-being of the communities we serve. Our commitment to providing extraordinary healthcare begins with our team of extraordinary professionals who are continuously discovering clinical innovations and enhancing access to the most up-to-date facilities, equipment, technologies, and research protocols. Cayuga Health's commitment to our employees includes competitive compensation, comprehensive employee benefits programs, and the opportunity to explore and build a career in healthcare through our many professional development programs. 


Our recent affiliation with Visiting Nurse Service of Ithaca and Tompkins Counties (VNS) provides additional opportunities to support our patients in their home environment through programs like the Community Medicine Program.


In the Community Medicine Program, the Care Transition Specialist is a critical role in the conversion of patient care from hospital to home, guiding and facilitating our efforts to eliminate re-hospitalization post discharge. Reporting to the Manager, Transportation and EMS, you will act as a care intermediary between the patient, their primary care physician, and the hospital, supporting their continuing recovery, health education and ongoing care services.


Roles and Responsibilities:

  • Guide and facilitate the introduction and initiation of new patients into the Community Medicine Program lead by VNS
    • See patients in hospital to educate and initiate them into the VNS program and schedule their initial care transition visit post discharge
    • Post discharge, see patients in home (regularly scheduled and ad-hoc visits) to provide them with the necessary health literacy, care and contacts to avoid re-hospitalization
    • Assist the patient in-home in scheduling follow up tele-health appointments with their PC
  • As part of the care regimen and when necessary, either as part of emergent care or in support of tele-health services provided by the patient's PC
    • Stabilize patient at home and connect with PC for evaluation
    • Perform patient assessments, collect vitals and essential patient information and communicate it to the PC
    • Assist virtual PC in evaluation of patient during tele-health appointments

Required Skills and Experience:

  • EMT-B Certification and CPR Certification
  • Valid Drivers License
  • Demonstrable understanding of anatomy and physiology as related to patient assessment and care
  • Strong written and verbal communication skills as related to patient assessment and care documentation and verbal communication to other medical professionals of varying roles and experience.
  • This role is somewhat self-managed in its location and function. Must be able to manage their time and patient calendar effectively with limited guidance.

Preferred Skills and Experience:

  • AEMT is Preferred
  • 2+ years of experience on an ambulance (active or volunteer)

Physical Requirements:

  • Able to drive, traverse, maintain stationary position, bend, pull, push, carry, and lift up to 50 pounds on a regular basis

Location and Travel Requirements:

  • Onsite in the hospital environment and Offsite in the patient's home
  • Daily travel to and from the hospital to the patient's home is required

Pay Transparency: $23.10 - $30.20 per hour


Cayuga Health System and its affiliates are committed to treating all patients, providers, staff and volunteers equitably and with dignity, ensuring the highest levels of safety, care and respect, and striving to recognize and overcome biases and policies that contribute to disparities in healthcare access, equitable care and positive health outcomes for all.


We are proud to be an Equal Employment Opportunity employer, supporting the growth and health of our employees and community by embracing the rich diversity, needs and circumstances of all peoples and prioritizing opportunities to build a diverse and inclusive workplace. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable protected characteristics.


If you require reasonable accommodation to complete a job application, pre-employment testing, a job interview or to otherwise participate in the hiring process, please contact the Cayuga Health Talent Acquisition team at talentacquisition@cayugahealth.org.


I certify that the information contained in this application is correct and complete to the best of my knowledge. I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added, or interpreted at any time, at the company's sole option and without prior notice to me.

I understand that any hiring decision is contingent upon my successful completion of all of the Company's lawful pre-employment/post-offer checks, which may include a background check, drug screen, employment references, and licensing review. If I am made a conditional offer of employment, I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment/post-offer checks. Such checks will not be conducted until allowed under applicable federal, state, and local law. I understand if I have a criminal background, it will not automatically disqualify me from employment unless otherwise required by law. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment checks.

I also understand that the Company is a drug and alcohol-free workplace and has a drug and alcohol testing program consistent with applicable federal, state, and local law. I understand that after a conditional offer of employment, I must submit to and pass a pre-employment drug test as a condition of employment.



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