The Care Transitions Coach is key to ensuring safe and effective transfers in the movement of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g. hospital) and patient and/or family. All Coaches provide information and guidance to the patient and/or family for an effective care transition, to improve self-management skills and enhance patient-practitioner communication, by assisting patients with the development of a personal health record; practice medication management; schedule follow-up appointments with their physician/specialist; and learn to recognize symptoms that indicate their condition is worsening and how to appropriately respond.
• Coach may collaborate with physicians and inpatient clinical hospital staff
• Conducts daily hospital visits
• Coach will prioritize referrals and activities according to intensity, need, and required follow-up
• Conducts in-home visits, Skilled Nursing Facility (SNF) visits and follow-up phone calls within the guidelines of the program
• Maintains accurate and timely documentation on each referred patient as well as readmitted patients in database system including complete and concise journal entry notes
ESSENTIAL SKILLS AND EXPERIENCE
• Advanced user of software applications to include Microsoft Office, Excel, Outlook and Case Management Systems
• Working knowledge of health care industry, caregiving, chronic disease management
• Knowledge and appreciation of cultural diversity and low literacy issues in care provision
• Decision making – handles all daily responsibilities relative to coaching a patient. Informs supervisor and works closely with supervisor with changes in patient’s condition
• Excellent verbal, written and computer literacy required
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness/efficiency. Adapts to changing patient or organizational priorities
• Ability to self-motivate and work independently, while collaborating with other team members
• Ability to work with patient/families of all ages and in a variety of settings, including inpatient facility and patients’ homes presenting diverse physical conditions and social/cultural environments
• Degree preferably in Health or Human Services, Care Coordination and/or at least 3 years of experience in Healthcare. Familiar with a wide variant of community resources
• Independent Travel in Service Area to hospitals, skilled nursing facilities and member homes
• Must possess a valid driver’s license, relevant certifications, etc.
Benefits to include: Medical, Dental, Vision, 401K Retirement, Paid Leave, etc.
FLSA: This is an exempt position.
Salary starts at $35,568/annually.
Equal Employment Opportunity Employer (EOE)
Bay Aging is the premier provider of programs and services allowing people of all ages to live independently in their communities for as long as possible. Formed in 1978, Bay Aging serves a predominately rural 2,600 square mile region that encompasses ten counties and two planning districts. As you will see, Bay Aging is extremely diverse in the programs it offers through three major divisions-Health/Community Living, Bay Transit, and Bay Family Housing.