Transitional Care Specialist

Welcome to CHI Saint Joseph Medical Group, a full service network of primary care services specializing in family, internal, geriatric and pediatric care serving 88 locations across central and Eastern Kentucky. CHI Saint Joseph Medical Group is dedicated to delivering customized care based on the unique needs of our patients and is recognized as a Best Place to Work in Kentucky for two years in a row (2023-2024). 

CHI Saint Joseph Health is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 team members and 25,000 physicians and advanced practice clinicians. 

Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians, advanced practice clinicians, nurses, and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2,200 care centers serving 24 states. 

$3000 sign on bonus for eligible applicants!

Job Summary / Purpose 

The primary objective of the Transitional Care Specialist  is to facilitate a smooth transition for patients from inpatient settings to community-based environments, such as their homes. By strategically deploying in-house representatives within the inpatient units and the Emergency Department to provide care coordination and patient education, the program aims to reduce readmission rates, improve patient outcomes, and enhance overall patient satisfaction and experience.

Essential Key Job Responsibilities

1. Position will be based on site- is not a remote position.
2. Calls patients following their Hospital or Emergency Department visit, based on criteria relating to the patient's health, social situation, community needs, risk factors, and needs for follow up care provider(s) within two business days of discharge.  Schedules face to face visit within 7-14  calendar days of discharge.
3.  Actively listens with caring and empathy and responds with appropriate inquiries to address any questions, issues or barriers noted in moving forward with the patient's ability to self-manage their care, treatment and services. 
4. Tracks all patient follow-up phone calls and based on the discussion with the patient, refers to appropriate individuals and disciplines within or outside the hospital for further discussion, education, training or other follow-up.
5.  Education to support self-management, independent living, and activities of daily living.
6. Assessment and support of treatment regimen adherence and medication management.
7. Identification of available community and health resources.
8. Assistance in accessing needed care and services.
9. Medication Reconciliation and post-discharge telephone calls.
10. Identifies potential barriers to getting timely and appropriate care and works to reduce them.
11. Works with the community and primary care providers to determine and assign a primary care provider based on the patient's needs and supported by their insurance provider.
12. Helps the patient through the initial phases of getting a follow-up appointment (when necessary) as well as the administrative and other support processes designed to assure timely and appropriate care, treatment and services.
13. Follows high risk patients (based on criteria) for up to 30 days to assure continued use of required resources designed to support both health and social needs.
14. Provides necessary patient information to the patient's care provider(s) to assure coordination of care.
15. Communicates with the patient or patient's care partner about information needed and provided to assure a smooth transition to the appropriate care providers.
16. Provides education and training to the patient or patient's care partner regarding the importance and appropriateness of using the primary care provider for optimal health care.
17. Summarizes patient information captured for analysis and helps clinical care practitioners and hospital teams come to conclusions designed to improve processes in care, treatment or services provided to patients.
18. Identifies opportunities for improvement relating to barriers experienced by patients in getting to a place of self-management of their health care needs.
19. Works collaboratively with the health care team to take action on and improve opportunities for improvement identified through any and all activities and tasks noted.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

-HS Diploma or equivalent required

-Current/valid Certified Medical Assistant (CMA) certification required or Registered Medical Assistant (RMA) required if applicable, OR: Current/valid Licensed Practical Nurse (LPN) licensure 

-BLS – CPR certification required within 5 days

Ability to listen attentively with empathy and capture essential information for continuity of care.

 -Ability to work collaboratively with all care professionals

including physicians, nursing, and external

community agencies and post-acute care

facilities. 

-Ability to complete required data entry in a timely manner.