Ambulatory Transition Care Coach - Care Center

The Ambulatory Transitional Care Coach is responsible for providing outreach and care coordination to patients recently discharged from an inpatient or observation hospital setting. The goal of this position is to aid in the scheduling of transition of care visits within 7- 14 days post-discharge. This position also provides patient support for referrals and community resources that encourage quality outcomes, smooth transitions, and coordination of care across the care continuum. This position is accountable for working with and representing Independence Health System across multiple internal and external partners.

Essential Job Functions

• Ensure positive customer service atmosphere and interactions in reception area.

• Ability to succeed in managing workload in a self-directed work environment

• Interacts with co-workers, internal and external customers in a courteous and respectful manner.

• Processes telephone calls and messages promptly, accurately, courteously, and efficiently.

• Follows recommended department guidelines for triage and scheduling of patients.

• Assists in maintaining/decreasing organizational/departmental costs.

• Works directly with primary care offices in achievement of EHMG quality metrics

• Schedules patients for appropriate intervals and provider based on protocols.

• Hospital-based position with expectation of varying direct bedside patient interactions

• Provides instructions and directions based on protocols and physician order.

• Assists the patient to meet insurance requirements for continued care.

• Process referrals in a timely manner.

• Demonstrates accountability for professional development.

• Acts as a patient advocate.

• Demonstrates the ability to solve problems and seeks assistance from immediate supervisor when appropriate

• Other duties as assigned.

Specialty Job Functions

• Provides scheduling support, outreach, education, and other needed activities to patients, provider referrals and community associates.

• This will include the facilitation and scheduling of all post-discharge appointments for Independence Health System attributed patients, either at the bedside or as follow-up.

• Documents all necessary components of the transitional care management visit.

• Responsible for initiating the medication reconciliation by tasking and notifying the appropriate care teams of patient discharge.

• Contributes to a positive patient experience, and identifies opportunities to enhance patient satisfaction.

• Communicates with case management to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources.

• Acts as a liaison between referral sources, facilities, and external entities to prevent and/or resolve continuum of care issues.

• Remains current on industry trends, best practice operational models, and changing patient and provider needs.

• Collaborates with care management, transitional care, home health, and other associated resources to ensure all necessary documentation in properly communicated for timely follow up.

Required Qualifications

• High School Diploma, GED or higher level of education.

• Three (3) years' experience in a healthcare (inpatient/outpatient) atmosphere.

• Demonstrated work experience using a computer and proficiency using Word & Excel.

• Demonstrated customer service and patient interaction experience.

• Strong leadership ability, good organizational skills, independent and critical thinking skills, and sound judgment.

• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

Preferred Qualifications

• Preferred Medical Assistant or LPN experience

License, Certification & Clearances

• Act 34-PA Criminal Record Check from the PA State Police system

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).

• Travel may be expected locally between Independence Health System locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one's own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Independence Health System's missions, vision and values.

AAP/EEO

• Independence Health System is an Equal Opportunity Employer. It is the policy of Independence Health System to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Independence Health System will conform to the spirit as well as the letter of all applicable laws and regulations.

• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential

• Absolute Necessity.

Marginal

• Minimal Necessity.

Constantly

• 5.5 to 8 hours or more or 200 reps/shift.

Frequently

• 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally

• 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely

• Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Extreme Heat

X

Extreme Cold

X

Heights

X

Confined Spaces

X

Extreme Noise(>85dB)

X

Mechanical Hazards

X

Use of Vibrating Tools

X

Operates Vehicle (company)

X

X

Operates Heavy Equipment

X

Use of Lifting/Transfer Devices

X

Rotates All Shifts

X

8 Hours Shifts

X

X

10-12 Hours Shifts

X

On-Call

X

Overtime(+8/hrs/shift; 40/hr/wk)

X

X

Travel Between Sites

X

X

Direct Patient Care

X

X

Respirator Protective Equipment

X

X

Eye Protection

X

X

Head Protection (hard hat)

X

Hearing Protection

X

Hand Protection

X

X

Feet, Toe Protection

X

Body Protection

X

X

Latex Exposure

X

X

Solvent Exposure

X

Paint (direct use) Exposure

X

Dust (sanding) Exposure

X

Ethylene Oxide Exposure

X

Cytotoxic (Chemo) Exposure

X

Blood/Body Fluid Exposure

X

X

Chemicals (direct use) Exposure

X

X

Mist Exposure

X

Wax Stripper (direct use)

X

Non-Ionizing Radiation Exposure

X

Ionizing Radiation Exposure

X

Laser Exposure

X

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Essential

• Absolute Necessity.

Marginal

• Minimal Necessity.

Constantly

• 5.5 to 8 hours or more or 200 reps/shift.

Frequently

• 2.5 to 5.5 hours or more or 32-200 reps/shift.

Occasionally

• 0.25 to 2.5 hours or 2-32 reps/shift.

Rarely

• Less than 0.25 hours or less than 2 reps/shift.

Physical Condition

Essential

Marginal

Constantly

Frequently

Occasionally

Rarely

Never

Bending (Stooping)

X

Sitting

X

X

Walking

X

X

Climbing Stairs

X

X

Climbing Ladders

X

Standing

X

X

Kneeling

X

Squatting (Crouching)

X

X

Twisting/Turning

X

Keyboard/Computer Operation

X

X

Gross Grasp

X

Fine Finger Manipulation

X

X

Hand/Arm Coordination

X

X

Pushing/Pulling(lbs. of force)

X

X

Carry

X

X

Transfer/Push/Pull Patients

X

Seeing Near w/Acuity

X

X

Feeling (Sensation)

X

Color Vision

X

X

Hearing Clearly

X

X

Pulling/Pushing Objects Overhead

X

Reaching Above Shoulder Level

X

Reaching Forward

X

X

Lifting Floor to Knuckle

9 LBS

X

Lifting Seat Pan to Knuckle

9 LBS

X

Lifting Knuckle to Shoulder

9 LBS

X

Lifting Shoulder to Overhead

9 LBS

X

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.