Transitional Care Specialist
The posted compensation range of $18.34 - $25.21 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.
$3000 sign on bonus for eligible applicants!
Job Summary / Purpose
The primary objective of the Transitional Care Specialist is to facilitate a smooth transition for patients from inpatient settings to community-based environments, such as their homes. By strategically deploying in-house representatives within the inpatient units and the Emergency Department to provide care coordination and patient education, the program aims to reduce readmission rates, improve patient outcomes, and enhance overall patient satisfaction and experience.
Essential Key Job Responsibilities
- Position will be based on site- is not a remote position.
- Calls patients following their Hospital or Emergency Department visit, based on criteria relating to the patient's health, social situation, community needs, risk factors, and needs for follow up care provider(s) within two business days of discharge. Schedules face to face visit within 7-14 calendar days of discharge.
- Actively listens with caring and empathy and responds with appropriate inquiries to address any questions, issues or barriers noted in moving forward with the patient's ability to self-manage their care, treatment and services.
- Tracks all patient follow-up phone calls and based on the discussion with the patient, refers to appropriate individuals and disciplines within or outside the hospital for further discussion, education, training or other follow-up.
- Education to support self-management, independent living, and activities of daily living.
- Assessment and support of treatment regimen adherence and medication management.
- Identification of available community and health resources.
- Assistance in accessing needed care and services.
- Medication Reconciliation and post-discharge telephone calls.
- Identifies potential barriers to getting timely and appropriate care and works to reduce them.
- Works with the community and primary care providers to determine and assign a primary care provider based on the patient's needs and supported by their insurance provider.
- Helps the patient through the initial phases of getting a follow-up appointment (when necessary) as well as the administrative and other support processes designed to assure timely and appropriate care, treatment and services.
- Follows high risk patients (based on criteria) for up to 30 days to assure continued use of required resources designed to support both health and social needs.
- Provides necessary patient information to the patient's care provider(s) to assure coordination of care.
- Communicates with the patient or patient's care partner about information needed and provided to assure a smooth transition to the appropriate care providers.
- Provides education and training to the patient or patient's care partner regarding the importance and appropriateness of using the primary care provider for optimal health care.
- Summarizes patient information captured for analysis and helps clinical care practitioners and hospital teams come to conclusions designed to improve processes in care, treatment or services provided to patients.
- Identifies opportunities for improvement relating to barriers experienced by patients in getting to a place of self-management of their health care needs.
- Works collaboratively with the health care team to take action on and improve opportunities for improvement identified through any and all activities and tasks noted.
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
Qualifications
-HS Diploma or equivalent required
-Current/valid Certified Medical Assistant (CMA) certification required or Registered Medical Assistant (RMA) required if applicable, OR: Current/valid Licensed Practical Nurse (LPN) licensure
-BLS – CPR certification required within 5 days
Ability to listen attentively with empathy and capture essential information for continuity of care.
-Ability to work collaboratively with all care professionals
including physicians, nursing, and external
community agencies and post-acute care
facilities.
-Ability to complete required data entry in a timely manner.
Overview
Welcome to CHI Saint Joseph Medical Group, a full service network of primary care services specializing in family, internal, geriatric and pediatric care serving 88 locations across central and Eastern Kentucky. CHI Saint Joseph Medical Group is dedicated to delivering customized care based on the unique needs of our patients and is recognized as a Best Place to Work in Kentucky for two years in a row (2023-2024).
CHI Saint Joseph Health is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 team members and 25,000 physicians and advanced practice clinicians.
Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians, advanced practice clinicians, nurses, and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2,200 care centers serving 24 states.
Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.
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Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit https://www.commonspirit.careers/benefits.
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Equal Opportunity
CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.
CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.