The posting
- 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
- Associate's degree and two years related work experience; or equivalent combination of education and work experience.
- Demonstrated proficiency in both verbal and written communication.
- Familiarity with an extensive range of community resources, social services, and support systems (such as housing, income assistance, and legal aid).
- Strong dedication to maintaining member confidentiality while strictly adhering to relevant legal and ethical standards.
- Basic working knowledge with Microsoft Office (Word, Excel, Outlook).
- Reliable home internet.
- Must possess reliable transportation for attendance at in-person (face-to-face) meetings.



