Transitions of Care Specialist

Summary:
Assists with telephonic care coordination for patients after emergency room hospital and skilled nursing facility admissions.

Responsibilities:
Assists with telephonic patient care and related tasks; assists in obtaining patient histories medication reconciliation and coordinating with care team members including Physicians Advanced Practitioners Nurse Care Managers Pharmacists and Social Workers
Leverages SMS and Remote Patient Monitoring (RPM) engagement for appropriate population panels
Screens patient panel using provided criteria and works closely with Care Management Team to identify rising risk or high-risk status
Responsible for following up on notifications of patient admissions and discharges per protocol and alerting care team members as needed
Educates patients on specified medical issues within established parameters
Has understanding and awareness of community and BHMGPC resources and teams to offer to patients
Refers and warm transfers to appropriate NCM or BHMGPC clinical program when appropriate
Schedules or assists in coordination of appointments with PCP or Specialty Provider
Participates in Care Conference for interdisciplinary care team management
Participates in team meetings to improve process(es) within program and ACO
Collaborates with TOC RNs to provide seamless hand-off when appropriate
Complies with federal and local confidentiality laws including HIPAA ensuring patient privacy
Adheres to Brown Health Medical Group Primary Care guidelines and policies for protecting patients� demographic clinical and financial information
Performs other job-related duties as assigned

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown Health Medical Group Primary Care USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union