Your Future is our Future

At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.

Position:

Transitional Care Specialist

Position Summary:

Responsible for helping patients and their families to navigate and access community services, other resources, and adopt healthy behaviors. Supports providers and Case Managers through an integrated approach to care management and community outreach. Responsible for will promoting, maintaining, and improving the health of patients and their family. Provides in-person, telephonic, and virtual support, advocates for individuals and community health needs, and provides services such as basic first aid and blood pressure screenings. Identifies and addresses concerns and patient needs and escalates unresolved matters through defined procedures.

Job Description:

Primary Responsibilities

• Establishes trusting relationships with patients and their families while providing general support and encouragement.
• Provides ongoing follow-up, basic motivational interviewing, and goal setting with patients/families. 
• Helps patients connect with transportation resources and provides appointment reminders in special circumstances. 
• Maintains knowledge about community resources appropriate to needs of patients/families.
• Provides consistent communication to the Case Manager to evaluate patient/family status, ensuring that provided information and reports clearly describe progress. 
• Acts as a patient advocate and liaison between the patient/family and community service agencies. 
• Reinforces education that has been provided by the licensed staff. 
• Provides health care and support to members/patients. Obtains vital signs, assists with ambulation, and confirms medication lists. 
• Assists patient/family with scheduling appointments with Lumeris providers/staff, as well as other providers (i.e., PCP, specialists); and coordination of durable medical equipment (DME) and supplies. 
• Assists with the Acute/Post Acute follow up as instructed. Completes pre-discharge calls or discharge reminder calls according to outlined processes. 
• May be asked to drive to a member’s home for wellness checks or locate if unable to reach telephonically. 

Qualifications

• Bachelor's degree in healthcare related field, LPN, or equivalent
• 3+ years of relevant experience or the knowledge, skills, and abilities to succeed in the role
• Firm interpersonal, critical thinking, and problem-solving skills, including the ability to interpret, conceptualize, and disseminate data/information in a readily understandable manner
• Good communication and presentation skills, both written and verbal, with the ability to effectively communicate with individuals at all levels internally and externally
• Effective time-management and project management skills, including the ability to plan, interpret moderately complex processes/programs, resolve and/or escalate issues in a timely fashion and ensure adherence to timelines
• Ability to collaborate as a member of an interdisciplinary team
• Excellent interpersonal and customer service skills, including telephone etiquette
• Proficiency using computer systems
• Ability to be flexible and adaptive to a changing environment
• Must have own reliable transportation for travel to/from members’ homes and the office as required

Working Conditions

• Ability to provide care to patients in their homes, both in person and virtually.
• Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs.  Ability to stand for extended periods.
• Ability to drive to patient locations (ie. home, hospital, SNF, etc).  Fine motor skills/visual acuity.

Disclaimer

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job du