Care Transitions Specialist II- Health Services

Care Transition Specialist II

Shift Schedule: MondayFriday, 9:00 AM 5:00 PM

Work Location: 247 West 37th Street, New York, New York 10018

JASA is one of NYCs largest and most trusted nonprofits serving older adults. Our dedicated professionals help improve the lives of thousands of seniors through impactful, mission-driven work.

Meaningful Clinical Impact: Leverage your healthcare knowledge to empower older adults to take control of their health, improve chronic disease management, and prevent avoidable hospitalizations.

Interdisciplinary Collaboration: Work directly with physicians, clinical pharmacists, health plan partners, and multidisciplinary teams to eliminate healthcare barriers and optimize patient care.

Valued Clinical Background: Apply your international medical or advanced clinical training in a supportive community health setting centered on health equity, motivational interviewing, and holistic patient advocacy.

The Medication Adherence Care Specialist plays a critical frontline role in JASAs Medication Adherence Program, bridging clinical healthcare and community-based support for older adults managing chronic conditions. Operating through structured telephonic outreach and in-home visits across New York City, you will assess adherence barriers, deliver targeted chronic disease education, and collaborate with healthcare providers and health plans to ensure medication plans are safely followed.

This role requires strong clinical communication, empathy, and cultural competence to address social determinants of health (SDOH), streamline pharmacy coordination, and guide members toward long-term wellness and independence.

Key Responsibilities:

• Member Outreach & Home Assessments: Conduct outbound telephonic outreach and in-home visits across NYC to assess physical needs, evaluate living environments, and deliver targeted medication adherence interventions.
• Chronic Disease & Medication Education: Educate members on disease self-management and the critical importance of adherence, focusing specifically on diabetes, hypertension (including RAS antagonists), and hyperlipidemia (statin therapy).
• Barrier Resolution & Care Planning: Identify and resolve individual adherence roadblocks, such as medication affordability, transportation gaps, side-effect concerns, health literacy deficits, and access to prescribers.
• Provider & Pharmacy Coordination: Liaise directly with physicians, pharmacies, caregivers, and health plan partners to facilitate prescription renewals, refills, 90-day supply conversions, medication synchronization, and prior authorizations.
• Social Determinants of Health (SDOH): Evaluate social needs and connect members to vital community resources, food assistance programs, and supportive social services.
• Clinical Documentation & Compliance: Record comprehensive, audit-ready encounter notes, home assessments, and progress milestones in Electronic Health Record (EHR) platforms and program databases in strict compliance with HIPAA and regulatory standards.
• Interdisciplinary Teamwork: Participate in case conferences, quality improvement initiatives, and interdisciplinary team meetings; promptly escalate urgent clinical or safety concerns to clinical supervisors.

What Youll Need:

• Education & Credentials: International Medical Graduate (IMG) or equivalent healthcare professional; clinical background in medicine, nursing, pharmacy, public health, or care management strongly preferred.
• Clinical Knowledge: Strong working knowledge of chronic diseases (diabetes, hypertension, hyperlipidemia), pharmacology basics, medication management, and chronic disease self-management principles.
• Language Proficiency: Bilingual fluency in English and Spanish (written and verbal) is required to serve diverse participant populations effectively.
• Field Mobility: Ability to travel throughout New York City via public transportation to conduct home assessments and independently negotiate physical stairs and environmental barriers within residences.
• Communication & Care Delivery: Strong telephone engagement and motivational interviewing skills; comfort communicating professionally with physicians, pharmacists, and health plan representatives.
• Technical Skills: Computer proficiency, including Microsoft Office Suite (Word, Excel, Outlook) and experience navigating Electronic Health Record (EHR) systems and health data platforms.
• Sector Knowledge: Familiarity with Medicare, Medicaid, managed long-term care (MLTC), and community resources is preferred.
• Cultural Competence: A deep understanding and appreciation of how race, religion, ethnicity, sexual orientation, and individual values shape healthcare choices and community care.

JASA offers a comprehensive benefits package designed to support your well-being and future:

• Health & Wellness: Medical (choice of 3 medical plans), dental, and vision coverage at low cost, plus Employee Wellness Programs and an EAP.
• Retirement Savings: 403(b) plan with Roth option and an employer-funded pension.
• Generous Time Off: Four weeks of vacation, plus holidays, floating holidays, and sick days.
• Professional Development: Opportunities for learning, clinical case conferences, and healthcare career growth.

EEO Statement: JASA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, genetic information, or any other protected classification under federal, state, or local law.