<p>Valley Health Partners</p> <p>Transition of Care Associate- Medical Assistant</p> <p>Patient Resource Center, Allentown, PA</p> <p>Job Summary:</p> <p>Hybrid work possible for this position. Interacts with patients/families to provide post-discharge transition of care outreach, linkage to care management resources, and care coordination in close collaboration with RNs on team and colleagues across the continuum. Acts as an integral part of the care team and is responsible for conducting patient outreach (telephonic and may do in-person home visits) to foster engagement with new and current patients. Assists in application of evidence-based practice through ensuring closure of care gaps and preventive health outcomes.</p> <p>Education:</p> <ul> <li>Associate's Degree Population Health, Public Health, or Health Care Administration or Technical School Diploma or active Certified Nursing Assistant Certification. </li><li>Bachelor's Degree Population Health, Public Health, or Health Care Administration, preferred. </li></ul> <p>Experience:</p> <ul> <li>1 year experience with customer service/service recovery and 1 year experience with care management and/or disease management or </li><li>1 year clinical experience and/or medical terminology. </li><li>More than 1 year of clinical experience in a healthcare or Federally Qualified Health Center (FQHC) setting, preferred. </li></ul> <p>Certificate/Training:</p> <ul> <li>MA - Medical Assistant </li></ul> <p>Needed Knowledge, Skills, and Abilities:</p> <ul> <li>Proficient in Microsoft Office applications. </li><li>Analytical way of thinking. </li><li>Leads with the initial set-up and ongoing management of all post-discharge and care gap reports and assumes responsibility for ensuring all tracking systems are appropriately updated through documentation. </li><li>Coordinates all patient engagement guidelines with the leads to ensure appropriate referral for ongoing Care Management services post-discharge. </li><li>Creates and maintains quality data and spreadsheets for reporting and presentation purposes. </li><li>Interacts with commercial payer groups, individuals, and leadership to drive effective clinical patient engagement strategies in conjunction with value-based contracting and quality initiatives. </li><li>Collaborates with the nursing team to discuss patient engagement tactics and review barriers to ongoing care coordination, post-discharge appointment scheduling, and care gap closure. </li><li>Organizes patient care activities and the sharing of information among all of the participants concerned with a patient's treatment to achieve more effective care including nursing team colleagues, ambulatory practices, and inpatient colleagues. </li><li>Ensures sustainable client relationships of trust by thoughtfully responding to client inquiries regarding process or technical matters. </li><li>Assists with the initial development of patient engagement and takes responsibility for maintaining all subsequent updates. </li><li>Performs other duties as assigned. </li></ul> <p>Benefits:</p> <ul> <li></li><li>Choice of medical, dental, and vision plans with great coverage at VERY affordable rates. </li><li>403b Retirement Plan with generous company match </li><li>Paid Time Off for holidays, vacation, sick & personal days </li><li>Employee Assistance Program </li><li>Tuition Reimbursement </li></ul>