Transition of Care Associate - Remote
Core
Coordinate care for members experiencing significant health changes requiring emergency, inpatient, skilled nursing, or rehabilitative stays to ensure seamless transitions and post-discharge goal attainment.
Role type
Senior clinical care coordinator (Transition of Care)
Builds
Post-discharge care plans, medication adherence, and community support services for high-risk members.
Domain
Healthcare / Care Management
Required skills
Discharge planning, medication management, prior authorization, care coordination, benefit education, case conference presentation, risk reduction strategies, interdisciplinary team facilitation, data reporting for utilization reduction.
Preferred skills
Bilingual communication, compact licensure.
Technologies
Microsoft Word, Excel, Outlook.
Responsibilities
Complete post-discharge questionnaires and discharge planning; ensure medication receipt and understanding; provide clinical assistance for services and supports; evaluate health and social indicators; identify barriers to optimal health; present cases at multidisciplinary conferences; coordinate post-discharge meal delivery and DME; update care plans for condition changes.
Seniority
Mid-level, hands-on IC