Essential job duties
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- 1.
- Hospital Transition Coordination (25%) Establishes direct contact with patients during hospitalization to assess needs, introduce transition support services, reinforce the importance of follow-up care, and begin discharge planning in collaboration with hospital staff.
- Serves as a liaison between the hospital team and GLBHC primary care site to coordinate timely follow-up appointments and support continuity of care after discharge.
- 2.
- Post-Discharge Follow Up Coordination (15%) Facilitates scheduling of hospital follow-up appointments with the patient’s GLBHC primary care site within recommended timeframes.
- Conducts post-discharge outreach to confirm appointments, reinforce discharge instructions, and support patient adherence to follow-up care plans in coordination with primary care nursing staff.
- 3.
- Barrier Identification and Resolution (20%) Assesses patient barriers to care including transportation, financial concerns, health literacy, insurance coverage, and other social determinants of health.
- Works collaboratively with internal staff and community resources to address barriers and facilitate successful attendance at follow-up visits.
- 4.
- Care Team Collaboration (15%) Works closely with providers, nurses, care managers, community health workers, and other care team members to support continuity of care following hospital discharge.
- Participates in care team meetings, huddles, and case discussions to ensure coordinated care plans for high-risk patients.
- 5.
- Patient Education and Support (15%) Provides guidance and education to patients and families regarding the importance of follow-up care, medication adherence, and available community resources.
- Supports patients in navigating the healthcare system and accessing services that promote recovery and ongoing health management.
- 6.
- Documentation and Data Tracking (10%) Maintains accurate and timely documentation of all patient interactions and coordination activities within the electronic medical record and applicable tracking systems.
- Monitors and reports transition-of-care performance indicators and assists in quality improvement initiatives related to hospital follow-up care.
Marginal job duties
1. Participates in team meetings.
Required job specifications
1.
Education
High school diploma or GED required. Associates degree in healthcare, social services, or related field preferred. 2.
Licensure
Community Health Worker (CHW) certification preferred. 3.
Experience
Minimum of two (2) years of experience in healthcare, care coordination, community health work, patient navigation, or related field required. Experience working with vulnerable populations or within primary care, hospital discharge planning, or care coordination strongly preferred. 4.
Skills
- Possesses basic knowledge and skill appropriate to education/training. Telephone and computer skills. Flexible in accepting work assignments. Bilingual (English/Spanish) preferred. 5.
- Interpersonal
- Skills: Possesses the ability to seek and utilize supervision appropriately. Ability to communicate effectively with a diverse patient population. Professional interpersonal communication skills. Ability to function as a committed and reliable team member. 6.
- Physical
- Effort: Must be able to sit, stand, and or walk for an entire workday. Must be able to lift, carry, push, pull, and or twist while holding up to 25 lbs. frequently. 7.
- Hours of
- Work: Full-time. Flexible and varied. Consistent attendance is required. Telecommuting is not available for this position. 8.
Travel
Will require travel within the GLBHC service area. Frequent/ daily travel to assigned hospital system required. Reimbursement consistent with GLBHC policy.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
