Transition Coordinator (Albany Region)

The Transition Coordinator will work in support of the Hospital to Home program by coordinating efforts of medical and behavioral health care managers to ensure that all members who are hospitalized leave with comprehensive discharge plans. The Care Coordinator may engage members and/or their loved one face‑to‑face in one of our Hospital to Home facilities and may collaborate with hospital treatment teams and discharge planners. Engagement may also occur over the phone and through electronic channels such as email, Microsoft Teams and fax. Outreach may include, but is not limited to: appointment setting, member communication about gaps in care and preventive health opportunities, member and provider education, communication campaigns, prior authorization processes for step‑down treatments, home care, durable medical equipment and medications. The Care Coordinator will assist with mail processing, materials organization, technology/service requests and other administrative tasks as necessary. This position is based in one or more Hospital to Home facilities and therefore requires hospital clearance and compliance with any hospital standards (e.g., physical exam, PPD, up‑to‑date vaccinations). Essential Accountabilities Work collaboratively with other members of the CDPHP Care Management team, including Registered Nurses and Social Workers, as well as collaborators from other areas of Member Health, Member Services and State Programs. Exhibit strong customer intimacy and ability to prioritize needs for complex hospital discharges, with support from clinical staff when needed. Engage effectively through written and verbal communication with both members and providers. Conduct targeted member and provider outreach via face‑to‑face engagement, phone calls and mail communication. Work collaboratively with members and families to build rapport and positively impact overall health status and compliance with health care service. Schedule member appointments and ensure timely sharing of hospital records with primary and specialty care providers, ensuring proper consents are in place. Schedule meetings and/or conferences by interacting with internal partners and/or external clients/partners to coordinate calendars, accommodations, meeting materials and supplies. Act as a resource pertaining to the authorization process for member/provider inquiries (requires familiarity with plan benefit design and CDPHP prior authorization process). Respond to ad‑hoc requests (filing, copying, responding to problems with printers, etc.). Coordinate and monitor project status and/or manage small projects/programs, and/or participate in larger projects representing the team. Practice and adhere to departmental, organizational and state guidelines. Contribute to several projects simultaneously and effectively; develop and implement new solutions that enhance efficiencies within the department. Participate in data collection through accurate documentation and record keeping. Adapt to changing work priorities and a fast‑paced environment while maintaining a professional attitude. Maintain comprehensive computerized records of all case management activities. Maintain effective, cooperative working relationships with people both internally and externally as it relates to the operations and business of CDPHP. Facilitate communication links among different disciplines involved in the member’s treatment. Work independently and maintain confidentiality at all times. Work additional hours as needed. Agree to comply with CDPHP’s Corporate Compliance Policy and all laws, rules, regulations and standards of conduct, reporting any suspected violations to the appropriate channels. Perform other duties as assigned. Minimum Qualifications Associate’s degree or two (2) years of equivalent experience required. Associate’s degree in human services or a related field preferred. Minimum one (1) year of experience working in customer service required. Experience with Government or State Programs populations preferred. Experience with and knowledge of social determinants of health required. Proficiency in Microsoft Outlook, Word, and Excel required. Knowledge or experience in PowerPoint, Access or other database software preferred. Strong understanding of community characteristics and resources in the local community preferred. Bilingual preferred. Excellent verbal and written communication skills. Demonstrated ability to pro‑actively identify problems, recommend and/or implement effective solutions. Demonstrated ability to work with and maintain confidential information. Demonstrated ability to provide excellent customer service and develop relationships both internally and externally. Excellent verbal and written communication skills. Flexibility to adapt to a changing and fast‑paced environment. Ability to travel locally as needed; access to reliable transportation and a valid driver’s license is required. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Compensation & Benefits Minimum: $19.22 – Maximum: $30.76 (N4). Actual salary will vary based on budget, prior experience, knowledge, skill and education as well as internal equity. The posted salary range reflects just one component of our total rewards package. Other components may include group health/dental insurance, retirement plan, wellness program, paid time away and paid holidays. Please note: there may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case‑by‑case basis. #J-18808-Ljbffr Capital District Physicians Health Plan, Inc.