Bilingual Medical Social Associate / Transition Coordinator - Continuum of Care

Position Summary:

The Medical Social Associate / Transition Coordinator acts as the primary contact for patient engagement with access to care, identification and reconnecting with patient Primary Care Physician and specialists, referrals to community-based resources and support, responsible for ongoing relationships with the healthcare community and ambulatory sites of care. The Associate will be responsible for evaluating/improving processes to access health care at UIH and within the community, identifying best practices that can be replicated, training and supervising volunteers of Patient Navigation services. They provide a variety of support services to the technical, professional, administrative or management operations of an organization. Reports to the Director, Care Management and/or Sr. Quality Specialist.

Duties & Responsibilities:

• Initiate communication with patient to educate and schedule follow up visits as necessary with their Primary Care Physician (PCP)
• Schedule follow up appointments as indicated by the medical team, in conjunction with the patient/caregiver.
• Assess in-network care locations for patient follow up, and educates patients and primary team regarding those options. Facilitates necessary referrals to outpatient sites of care.
• Guide patients through the health care system and assesses and resolves barriers to patients arriving at scheduled appointments on time and prepared.
• Assist patients in accessing services and programs at UIH and within the community; assists with setting up transportation if needed
• Facilitates patient interaction and communication with healthcare staff and providers
• Able to personally speak with constituents to assess their barriers in accessing care, through a state wide referral system.
• Work with patients to create a plan to reduce those barriers.
• Help provide the services and support that the patients and their families may require, including case management.
• Initiating external referrals in an effort to assist our patients
• Responsible for verifying patient demographics, including next of kin and emergency contact with each encounter.
• Comprehensively provides or recommends social service and private financial support to assure patients’ medication is affordable, resulting in greater clinical compliance to treatments and services.
• Attends committee meetings, medical rounds, and other planning/organizational meetings as requested.
• Identify and develop relationships with other referral sources.
• Participates in quality improvement initiatives and assists in collecting data regarding quality measures
• Identify gaps in resources offered and work within the community to bridge those gaps.
• Conduct follow-up calls to patients, families and caregivers as indicated
• Utilizes evidence/best practices when developing patient education materials
• Advises underinsured patients to take corrective actions to enhance their insurance coverage.
• Performs quality control review of a variety of administrative documents or transactions.
• Transportation requests by Medical staff and from patient or their families for the purpose of discharge from the Medical center, rides to or from clinical appointments or procedures.
• Complete Assessments for various Diagnostic issues, such as Stroke, HIV, Homelessness, RISK for Readmissions, etc.
• Perform other related duties and participate in special projects as assigned.