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About the Role
The Transitional Care Partner provides preventative care and outreach for varying at-risk populations. This role facilitates follow-up for patients after recent discharges from various healthcare settings, including hospitals and skilled nursing facilities. They are responsible for appointment setting, referring patients to appropriate agencies and community resources, and providing care coordination for clients facing chronic medical and behavioral health challenges impacted by social determinants of health. This position ensures optimal care through different EMR systems and healthcare platforms.
Responsibilities
- Facilitates bidirectional information exchange with hospital and primary care provider/team.
- Performs rounds to hospitals to meet with patients, admission personnel, case managers, and discharge planners.
- Performs outreach follow-up for patients who have had a recent discharge from inpatient hospitals, emergency rooms, postpartum units, or skilled nursing and rehabilitation facilities.
- Responsible for appointment setting and referring patients to appropriate agencies, specialty providers, and community resources.
- Obtains hospital records and ensures they are received in eCw.
- Identifies barriers to interdisciplinary collaboration and proposes strategies to improve TOC.
- Identifies needed follow-up on tests and indicates via appropriate EMR documentation.
- Coordinates patient documentation, such as discharge papers and medication lists, to prepare patients for healthcare provider visits.
- Obtains consultant reports, medical record releases, and consents.
- Manages an outreach schedule for patient follow-up and appointment setting.
- Provides care coordination with both internal and external stakeholders.
- Evaluates and assists patients with overcoming barriers to obtaining necessary appointments and medical care.
- Screens patients for factors influencing social determinants of health and initiates referrals using appropriate resources.
- Consults with the transition of care team and seeks clarification when needed.
- Identifies and escalates encounters that require complex care or medical triage.
- Participates in the development and implementation of patients' Transition of Care Plan, coordinating with nursing to meet established goals.
- Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff.
- Monitors and coordinates treatment plans as indicated by licensed clinical personnel.
Requirements
- HS Diploma
- 1 year of relevant experience
Location
- Peekskill, NY
Work Type
- Full-Time
Education Level
- HS Diploma
Salary/Compensations
- $24.00 - $25.67 per hour
Benefits
- Medical, Dental and Vision Insurance
- Life and Disability Coverage
- Retirement Savings Plan
- Commuter and Transit Benefits
- Employee Assistance Program (EAP)
- Employee Discount Program
- Provider Incentive Compensation Program: Quality & Productivity
- Provider Professional License, Certification and DEA Fees Reimbursement
- Tuition Reimbursement Program
About the Company
- Sun River Health has a rich history of providing quality, affordable health care to communities in need. Founded in the early 1970s by four African American women in Peekskill, New York, the organization was established to address the lack of accessible health services in their community. With the help of a small federal grant, the first Sun River Health site opened its doors in 1975. Over the years, Sun River Health has grown into a comprehensive Federally Qualified Health Center (FQHC) system with over 50 locations, serving more than 250,000 patients across the Hudson Valley, New York City and Long Island. Our exceptional primary care practitioners, specialists and support staff are dedicated to delivering high-quality care to all individuals, regardless of their ability to pay. In December 2018, Sun River Health expanded its reach by merging with Brightpoint Health, an FQHC network offering integrated medical, behavioral and social support services in New York City. This merger allowed us to enhance our services and continue our mission under the unified name of Sun River Health.
- At Sun River Health, we believe in fostering a culture of wellness, inclusivity and recognition. Our Workforce Wellness Program promotes staff wellness through ongoing challenges and activities, encouraging participation and rewarding engagement. We celebrate our staff's dedication and person-centered spirit through the Planetree Recognition Awards, which honor innovation, leadership and community spirit. We are committed to creating a supportive and collaborative work environment where all team members can thrive. Our values of respect, integrity and excellence guide our interactions with patients and colleagues alike, ensuring that everyone receives the care and support they deserve.
Equal Opportunity
- Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.