Posted 19 days ago
Description
- Assessment
- Triage member to identify medical, psychological, and social barriers to discharge then transition member to appropriate healthcare professional on their team such as TCN or CHW.
- Care Transition Collaboration
- Work with healthcare team to ensure safe and smooth member transitions
- Education
- Inform members and families about appointments and other care plan requirements.
- Follow-Up Coordination
- Schedule and monitor follow-up appointments with providers and community services.
- Post-Discharge Follow-Up
- Track member progress and address needs through calls following call cadence
- Refers to TCN for medical needs and CHW for community needs.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
