Transition of Care Associate

Lehigh Valley Health Network

. Conduct post-discharge transition-of-care outreach, including telephonic outreach and potentially in-person home visits .

Posted 10/28/2026part-timeRemote • Pennsylvania • United StatesMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in post-discharge care coordination, patient engagement, and data management within a complex health system. Proficient in utilizing electronic medical records and Microsoft Office applications to enhance patient care and communication.

Highest-signal resume keywords

Post-Discharge Care CoordinationPatient EngagementElectronic Medical RecordsMicrosoft Office ProficiencyAnalytical Thinking

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care ManagementData ManagementMedical TerminologyScheduling SoftwareQuality Reporting

Soft Skills

Customer ServiceEffective CommunicationCritical ThinkingAdaptabilityAnalytical Thinking

Tools & Technologies

Electronic Medical RecordsMicrosoft Office ApplicationsTracking Systems

Certifications & Qualifications

LPN CertificationMedical Assistant Certification

Industry Keywords

Healthcare ExperienceCare CoordinationPatient-Care ActivitiesInterdisciplinary TeamsConfidentiality

About the role

Key responsibilities & impact

Conduct post-discharge transition-of-care outreach, including telephonic outreach and potentially in-person home visits
Link patients to care-management resources and coordinate care with interdisciplinary teams
Foster engagement with new and current patients
Ensure closure of care gaps and preventive health outcomes using evidence-based practices
Set up and manage post-discharge and care-gap reports
Update tracking systems through documentation
Collaborate with commercial payer groups, individuals, leadership, nursing teams, ambulatory practices, and inpatient colleagues
Discuss patient-engagement tactics and barriers to care coordination
Coordinate post-discharge appointment scheduling and care-gap closure
Organize patient-care activities and information sharing among treatment participants
Coordinate referral for ongoing care-management services after discharge
Create and maintain quality data and spreadsheets for reporting and presentations
Respond to client inquiries about processes or technical matters
Develop and maintain patient-engagement processes and updates

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: one of the listed LPN or medical assistant certifications upon hire
Ability to lift and carry 25 lbs.; frequent sitting/standing and keyboard use; patient-care activities may include kneeling, bending, squatting, and CPR

Benefits

Comp & perks

Equal opportunity employment
Day shift
Monday-Friday schedule with weekend rotation; variable shifts and hours