Transition of Care Partner - New York

Sun 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**** Summary: The 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. Responsibilities: * Facilitates bidirectional information exchange with hospital and primary care provider/team * Performs rounds to hospital where indicated to meet with patients, admission personnel, case managers, discharge planners, others * Performs 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 facilities * Responsible for appointment setting, referring patients to appropriate agencies, specialty providers, and community resources * Obtain hospital records and ensures records are received (scanned/e-faxed) in eCw. Identifies barriers to interdisciplinary collaboration and proposes strategies to improve TOC * Identifies needed follow-up on tests or and indicates via appropriate EMR documentation * Coordinates 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 consents * Accountable for managing an outreach schedule for patient follow-up and appointment setting, while providing care coordination with both internal and external stakeholders * Evaluates and assists patient with overcoming barriers to obtaining necessary appointments and medical care * Screens patients for factors influencing social determinants of health and initiates referrals using appropriate resources * Consults with transition of care team and seeks clarification when needed; identifies and escalates encounters that require complex care or medical triage * Participates in development and implementation of patients Transition of Care Plan, coordinating with nursing, to meet established goals * Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff * Monitor and coordinates treatment plans as indicated by licensed clinical personnel * Identifies, refers, and maintains continuity of care for patients requiring high-risk care management, while collaborating with licensed clinical staff Requirements:

• HS Diploma
• 1 year of relevant experience

Preferred Specialized Skills & Knowledge: Bilingual in both English and Spanish (orally and written) Job Type: Full Time Pay: $23.00 - $26.37 per hour