Transition of Care Associate

Join a team that delivers excellence.

Lehigh Valley Health Network (LVHN) is home to nearly 23,000 colleagues who make up our talented, vibrant and diverse workforce.

Join our team and experience firsthand what it's like to be part of a health care organization that's nationally recognized, forward–thinking and offers plenty of opportunity to do great work.

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward–thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital – Cedar Crest, Lehigh Valley Hospital – Muhlenberg, Lehigh Valley Hospital– Hazleton, and Lehigh Valley Hospital – Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Interacts with patients / families to provide post–discharge transition of care outreach, linkage to care management resources, and care coordination in close collaboration with RNs on 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.

Job Duties

• 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.
• 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.
• 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.
• 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.

Minimum Qualifications

Preferred Qualifications

Physical Demands

Lift and carry 25 lbs. frequent sitting / standing, frequent keyboard use,

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.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and / or social activities.

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