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Transition of Care Associate
Lehigh Valley Health Network. Conduct post-discharge transition-of-care outreach to patients and families .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in patient outreach and care coordination within complex health systems, utilizing analytical thinking and effective communication to enhance patient engagement and improve health outcomes. Proficient in managing care-gap reports and maintaining quality data for reporting.
Highest-signal resume keywords
Patient OutreachCare CoordinationElectronic Medical RecordsMicrosoft Office ProficiencyCustomer Service Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Care ManagementData ManagementMedical TerminologyScheduling SoftwareAnalytical Thinking
Soft Skills
Effective CommunicationCritical ThinkingAdaptabilityCustomer ServiceConfidentiality
Certifications & Qualifications
LPNCCMACMACMACMACNCMANRCMARMA
Industry Keywords
Healthcare ExperiencePatient EngagementCare-Gap ClosureInterdisciplinary TeamsComplex Health System
About the role
Key responsibilities & impact- Conduct post-discharge transition-of-care outreach to patients and families
- Link patients to care-management resources and coordinate care with interdisciplinary teams
- Conduct telephonic patient outreach and potentially in-person home visits
- Foster engagement with new and current patients
- Help close care gaps and improve preventive health outcomes using evidence-based practice
- Lead the initial setup and ongoing management of post-discharge and care-gap reports
- Maintain tracking systems through documentation
- Interact with commercial payer groups, individuals, and leadership to drive clinical patient-engagement strategies
- Collaborate with nursing teams on engagement tactics, care-coordination barriers, appointment scheduling, and care-gap closure
- Organize patient-care activities and information sharing among nursing, ambulatory, and inpatient colleagues
- Coordinate patient-engagement guidelines and referrals for ongoing case-management services after discharge
- Create and maintain quality data and spreadsheets for reporting and presentations
- Respond to client inquiries regarding processes or technical matters
- Assist with development and maintain updates to patient-engagement processes
Requirements
What you’ll need- High School Diploma/GED with required years of healthcare experience OR Specialized Diploma in Medical Assistant or related field
- 3 years experience working within a complex health system environment OR less than 1 year experience with Specialized Diploma
- Proficient in Microsoft Office applications
- Analytical thinking
- Ability to handle numerous tasks at the same time
- Superior customer service skills
- Working knowledge of basic computer functionality
- Effective and professional written and verbal communication
- Ability to maintain strict confidentiality
- Ability to adapt to changing priorities
- Critical thinking skills and solution-focused approach
- Knowledge of medical terminology
- Knowledge and experience with electronic medical records and scheduling software
- Preferred: 5 years experience working within a complex health system environment
- Preferred: Bilingual
- Preferred certifications/licenses upon hire include LPN, CCMA, CMA, CMAC, MAC, NCMA, NRCMA, or RMA
- Ability to lift and carry 25 lbs.; frequent sitting/standing and keyboard use; patient care providers may need to kneel, bend, squat, and perform CPR
Benefits
Comp & perks- Full-time employment
- Day shift
- Monday-Friday work schedule with weekend rotation