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Healthcare Transitions Coach I in Chicago, IL at VisionPRO

Date Posted: 7/9/2018

Job Snapshot

Job Description


Healthcare Transitions Coach I - Job 72718
Job Summary:

  • Responsible for safely and effectively transitioning "Company" members, from acute or inpatient care to lower levels of care and/or home, in a cost-efficient manner.
  • Provides assessment, planning, implementation, coordination, monitoring, and evaluation of services for "Company" members, as they transition care; and follows them for 30 days, post discharge.
  • Conducts an onsite or telephonic hospital discharge visit, and post-discharge visit, to assure continuity of care and prevent unnecessary readmissions.
  • Refers complex cases to case management, as appropriate, based on consultation with the Interdisciplinary Team.


Essential Functions:

  • Identifies, assesses, and manages "Company" members, during care transitions, per established criteria.
  • Coordinates transition of care, between inpatient and other settings with the practitioner, Healthcare Services (HCS) staff, community-based agencies, social workers, hospital/nursing facility discharge planner, and/or other providers, as required.
  • Coordinates necessary services, with participating ancillary service providers and public agencies, as appropriate to ensure quality, cost effective care, and reduced readmissions for the member.
  • Conducts one discharge planning hospital visit or telephone call with the member or member's designee, at assigned facilities, prior to discharge, and one home visit or telephone call to member, after discharge to:
    • Discuss the "Company" Transition of Care Program.
    • Identify staff and roles, as they differ from the facility staff (all "Company" staff must wear "Company" identification for all facility and or home visits).
    • Introduce Personal Health Record (PHR).
    • Review Discharge Plan and member's understanding of the plan.
    • Evaluate current medications, via the medical record, or advise the member to request that facility staff review the medication list.
    • Discuss the importance of understanding prescribed medications, and having a system in place, to ensure adherence to the regimen.
    • Discuss the Medication Record.
    • Facilitate appointment, with either the Primary Care Physician/Practitioner or treating specialist, within 5 days of discharge.
    • Provide information and contact numbers for "Company" resources (transportation, Nurse Advice Line (NAL), Care Coordination/Case Management, Behavioral Health).
    • Discuss emergency plan.
    • Conduct 3-4 additional telephone calls to members, over a 30-day period, to complete the Transition of Care protocol.
    • Conduct any additional calls, needed to facilitate TOC.
  • Develops a plan of care, consistent with sound medical, behavioral health, chemical dependency, and financial management. Includes assessment of health needs, individualized care plans and/or service plans, implementation, monitoring, and evaluation of case outcomes.
  • Consults with interdisciplinary care team to create care plan, as needed, and facilitate access to needed care and services.
  • Arranges for health care services, within the scope of available benefits.
  • Documents medical management within the electronic medical record system. Documentation includes assessments, service plans and/or care plans and updates, contacts, and planned tasks.
  • Reviews and updates care plans for continuity of care, and facilitates plan modifications, including barriers to goals and interventions for members being coached through the transition of care, from the inpatient and or skilled nursing facility.
  • Maintains active caseload and conducts expected face-to-face or telephonic visits, consistent with "Company" Healthcare standards.
  • Maintains department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
  • Attends meetings related to care coordination and HCS Department topics.
  • Provides coverage for other staff, as needed.
  • Other Duties, as assigned.
  • Complies with workplace safety standards.


Knowledge/Skills/Abilities:

  • Exceptional telephone manners and patience in handling a variety of callers.
  • Must have a courteous manner and positive attitude, when interacting with employees and customers.
  • Demonstrated adaptability and flexibility to changes, and response to new ideas and approaches.
  • Demonstrates professionalism, at all times.
  • Ability to independently use resources to solve problems.
  • Effective and culturally-sensitive communication skills. with individuals and families from diverse ethnic and cultural backgrounds.
  • Bilingual, based on community need.
  • Ability to motivate members to be active participants in their health.
  • Knowledge of applicable state, federal, and third-party regulations and standards (Medicare, Medicaid, Copes, MPC, SSI).
  • Comfortable working with Aged, Blind, Disabled, and Severely Mentally Ill populations, with varied economic and educational circumstances.
  • Maintains member respect and dignity, while displaying maturity, empathy, ethics, confidentiality, and professionalism.
  • Provides health education and advocacy to members and their families.
  • Must have a high regard for confidential information.
  • Ability to work in a fast-paced environment
  • Works independently and as part of a team.
  • Computer and Microsoft Office experience.
  • Accurate data entry at 40 WPM minimum.
  • Skilled at identification and elimination of barriers to receiving services.
  • Broad knowledge of area community resources/agencies.
  • Ability to develop and execute plans of care, and prepare reports, as needed or requested.


Required Education/Experience/ Licensure/Certification:

  • Bachelor's Degree, preferred, in area of preferred education or LVN course of study with license.
  • 1-2 years Medical Case Management experience.
  • 1-2 years Public Health experience.
  • Knowledge or experience using the Care Transitions Intervention or similar model.
  • Background in discharge planning and home health.
  • Active, unrestricted, State-Registered Nursing License, in good standing.


VisionPRO relentlessly delivers top talent to help our clients excel. We have been trusted for 20 years to align the right talent to the right opportunity, expertly solving unique business challenges. From small businesses to the Fortune 500, our clients appreciate our consultative approach, resourcefulness, and fast response to their individual needs. Our prospective candidates and existing consultants can count on VisionPRO to passionately help them maximize their career choices, while also supporting their growth opportunities. We serve our customers from around the world, helping them with their most critical hiring decisions and project needs.

Job Requirements

Responsible for safely and effectively transitioning "Company" members, from acute or inpatient care to lower levels of care and/or home, in a cost-efficient manner.
Provides assessment, planning, implementation, coordination, monitoring, and evaluation of services for "Company" members, as they transition care; and follows them for 30 days, post discharge.
Conducts an onsite or telephonic hospital discharge visit, and post-discharge visit, to assure continuity of care and prevent unnecessary readmissions.
Refers complex cases to case management, as appropriate, based on consultation with the Interdisciplinary Team.