Transition of Care Associate- Care Management ED Outreach

Job Details This role is remote. 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 Description

• 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.

Education - Required

• High School Diploma/GED with required years of healthcare experience or
• Specialized Diploma Medical Assistant or related field

Experience - Required

• 3 years experience working within a complex health system environment or
• Less than 1 year experience with Specialized Diploma

Experience - Preferred

• 5 years experience working within a complex health system environment

Knowledge, Skills and Abilities - Required

• 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.

Knowledge, Skills and Abilities - Preferred

• Bilingual

Licenses and Certifications - Preferred

• 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

Put People First

• Put People First: Create a safe environment where all colleagues feel supported and motivated to be their best at work.
• Build relationships: Build belonging, empathy, and collaboration.
• Engage with grace: Assume positive intent and share your perspective thoughtfully.
• Create moments: Affirm and acknowledge the contributions and efforts of others.

Do What's Right

• Do What’s Right: Focus on how we work most effectively to get the best results.
• Prioritize What Matters: Clarify what’s most critical and why.
• Align on Expectations: Translate priorities into agreed upon accountabilities and outcomes.
• Act with integrity: Behave ethically and honestly in all interactions and business practices.

Pursue Excellence

• Pursue Excellence: Focus on learning and growth.
• Look and Listen: Explore new ways of working and stay curious by learning from others.
• Innovate with Intent: Try new ideas that support organizational priorities.
• Value Lessons Learned: Acknowledge progress and insights that come from striving to improve.

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.

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. Work Shift Workday Day (United States of America) Worker Sub Type Regular Employee Entity Thomas Jefferson UniversityPrimary Location Address 1101 Market, Philadelphia, Pennsylvania, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance. For more benefits information, please click here Apply To This Job