Care Transition Specialist - Remote (PA/NJ/DE)
- Member Outreach & Engagement
- Contact members post-discharge to review discharge instructions, identify current needs, and escalate immediate needs to clinical team.
- Educate members on medication adherence, symptom monitoring, and follow-up appointments.
- Identify social determinants of health barriers and connect members to appropriate resources.
- Assists members with understanding their plan benefits and connects to member services.
- Care Coordination
- Assist with scheduling follow-up visits with network providers and specialists.
- Facilitate referrals to home health, durable medical equipment, and community-based services as needed.
- Collaborates with interdisciplinary team (nurse health coach and/or social workers) for consultation and referrals.
- Monitoring & Documentation
- Documents member outreach outcomes and barriers to care using health plan care management systems within scope of role.
- Document all interactions in compliance with organizational, regulatory, and NCQA standards.
- Monitor high-risk members and escalate concerns to clinical case managers as needed.
- Bachelor’s degree in health sciences, psychology, social work, or related field, nursing, public Health, or related field required.
- 1–2 years of experience in relevant work experience (healthcare, member-facing role such as case management and member outreach).
- Knowledge of managed care principles, discharge planning, and community resources.
- Strong communication and interpersonal skills.
- Excellent written and verbal communication skills.
- Ability to work independently and manage multiple priorities.
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