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Care Transition Specialist

2 months ago

Bend, Oregon, United States Summit Health, Inc. Full time
About Our Company

We are a leading healthcare organization committed to delivering high-quality, patient-centered care. Our team of dedicated professionals is passionate about simplifying healthcare and bringing a more connected approach to care.

Job Description

Position Summary:

The Care Transition Specialist plays a critical role in supporting and promoting the care transitions and social support needs of patients across the continuum of care. This position collaborates with healthcare providers, care managers, social workers, and other stakeholders to facilitate seamless transitions of care, social support interventions, and patient outreach and engagement to close care gaps.

Key Responsibilities:
  • Establish and maintain relationships with hospitals, rehabilitation facilities, and other post-acute care facilities to promote ongoing collaboration and regular communications.
  • Conduct routine outreach calls to gather critical clinical information about admitted patients and demonstrate effective relationship-building skills.
  • Work collaboratively with internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative workflow standards.
  • Initiate and complete the transition of care process on behalf of client providers and ensure a seamless handoff of information to care managers and other interdisciplinary team members.
  • Manage low-risk patients discharged from inpatient facilities by providing outreach and adhering to established care pathways and algorithms.
  • Collaborate with social support teams and manage information, referral, and assistance inquiries received, ensuring timely and efficient outreach to patients, family members, and caregivers.
  • Identify patients not meeting clinical goals or important quality metrics and arrange follow-up by protocol, as appropriate.
  • Review and update medication lists and accurately document known allergies in the electronic health record.
  • Record patient information accurately to support population health initiatives and update data worksheets with outcomes following patient contact and recommendation of needed services and appointments.
  • Facilitate and arrange new patient and follow-up services per treatment protocol, as appropriate.
General Job Functions:
  • Collect, track, trend, and report clinical data for all transitions of care program patients, low-risk care management patients, social support program patients, patients discharged from the emergency department, and patients requiring outreach for closing care gaps.
  • Maintain information flow and communications with non-SMG collaborating providers to ensure efficient patient care.
  • Demonstrate appropriate and timely use of the electronic health record.
  • Attend all pertinent departmental meetings and trainings that involve care management teams, social support programs, and hospitalist workflows.
  • Assist with special projects as assigned and complete them within required timelines.
  • Effectively communicate problems, concerns, or issues to the supervisor and/or manager appropriately and promptly.
Home Visit Job Functions:
  • Engage and collaborate with care managers, social workers, clinic staff, and providers to schedule and prepare for identified in-home virtual visits.
  • Communicate with patients during in-home virtual visits and complete rooming processes, including facilitating technology to initiate visits, obtain vitals, complete screenings, and collect lab specimens as needed.
  • Maintain HIPAA-compliant workflows while in patients' homes and while transporting specimens and documentation to clinics.
  • Manage supplies and equipment needed for home visits, such as tablets, computers, hotspots, vital signs, and lab collection equipment.
Education, Certification, Computer, and Training Requirements:
  • Bachelor's degree preferred but not required.
  • 2-4 years of relevant work experience in the healthcare field is preferred.
  • Certified medical assistant, licensed practice nurse in the state of Oregon, EMT-B, or paramedic preferred, or other relevant clinical experience considered.
  • BLS certification required for in-person patient-facing positions.
  • Valid driver's license for patient-facing positions.
  • Experience in primary care, family practice, internal medicine, urgent care, or ER preferred.
  • Must be proficient in computer skills and Microsoft Office, Excel, Word, and PowerPoint.