Transition of Care Partner - New York

Job DescriptionSun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who see it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a Full-time Transition of Care Partner to join our team in our New York, NY site. $1500 Sign On Bonus- Terms and Conditions Apply****SummaryThe Transition Care Partner provides preventative care and outreach for varying at risk populations. Facilitates follow-up for patients who have had a recent discharge, including but not limited to: inpatient hospital discharges, emergency room visits,­ postpartum units, skilled nursing and rehabilitation facilities. They are responsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resources. Provides care coordination and support to clients overcoming barriers with chronic medical and behavioral health that are also impacted by social determinants of health. Provide optimal care through differing EMR systems and healthcare platforms.ResponsibilitiesFacilitates bidirectional information exchange with hospital and primary care provider/teamPerforms rounds to hospital where indicated to meet with patients, admission personnel, case managers, discharge planners, othersPerforms outreach follow-up for patients who have had a recent discharge, including but not limited to: inpatient hospital discharges, emergency room visits, postpartum units, skilled nursing and rehabilitation facilitiesResponsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resourcesObtain hospital records and ensures records are received (scanned/e-faxed) in eCw. Identifies barriers to interdisciplinary collaboration and proposes strategies to improve TOCIdentifies needed follow-up on tests or and indicates via appropriate EMR documentationCoordinates patient documentation such as hospital discharge papers, medication lists, and visit summaries, that will prepare the patient for the healthcare provider visit. Obtains consultant reports, medical record releases and consentsAccountable for managing an outreach schedule for patient follow-up and appointment setting, while providing care coordination with both internal and external stakeholdersEvaluates and assists patient with overcoming barriers to obtaining necessary appointments and medical careScreens patients for factors influencing social determinants of health and initiates referrals using appropriate resourcesConsults with transition of care team and seeks clarification when needed; identifies and escalates encounters that require complex care or medical triageParticipates in development and implementation of patients Transition of Care Plan, coordinating with nursing, to meet established goalsIdentifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staffMonitor and coordinates treatment plans as indicated by licensed clinical personnelIdentifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staffRequirementsHS Diploma1 year of relevant experiencePreferred Specialized Skills & Knowledge: Bilingual in both English and Spanish (orally and written)Job Type: Full TimePay: $23.00 - $26.37 per hourResponsibilitiesRelation to MissionThe mission of Sun River Health is to increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable.Equal Employment OpportunitySun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function.Americans with Disabilities ActApplicants as well as employees who are or become disabled must be able to perform the essential job functions either unaided or with reasonable accommodation. The organization shall determine reasonable accommodation on a case-by-case basis in accordance with applicable law.Job ResponsibilitiesThe following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of the position. Sun River Health may change the specific job duties with or without prior notice based on the needs of the organization.