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***$1,500 Sign On Bonus***

Summary:

The Transitional 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

Requirements:

• HS Diploma
• 1 year of relevant experience

About Sun River Health

Sun River Health has a rich history of providing quality, affordable health care to communities in need. Founded in the early 1970s by four African American women in Peekskill, New York, the organization was established to address the lack of accessible health services in their community. With the help of a small federal grant, the first Sun River Health site opened its doors in 1975. Over the years, Sun River Health has grown into a comprehensive Federally Qualified Health Center (FQHC) system with over 45 locations, serving more than 250,000 patients across the Hudson Valley, New York City and Long Island.

Our Culture

At Sun River Health, we believe in fostering a culture of wellness, inclusivity and recognition. Our Workforce Wellness Program promotes staff wellness through ongoing challenges and activities, encouraging participation and rewarding engagement. We celebrate our staff's dedication and person-centered spirit through the Planetree Recognition Awards, which honor innovation, leadership and community spirit. We are committed to creating a supportive and collaborative work environment where all team members can thrive.

Benefits

At Sun River Health, we are committed to building a personal relationship with our team and supporting you in every way we can. We offer competitive compensation and a comprehensive benefits package for you and your family, including:

• Medical, Dental and Vision Insurance: Comprehensive health coverage to ensure you and your family stay healthy.
• Life and Disability Coverage: Financial protection for you and your loved ones in case of unforeseen circumstances.
• Retirement Savings Plan: Plan for your future with our retirement savings options.
• Commuter and Transit Benefits: Assistance with your daily commute to make your journey to work easier.
• Employee Assistance Program (EAP): Access to confidential support and resources for personal and work-related issues.
• Employee Discount Program: Enjoy discounts on various products and services as a valued member of our team.
• Provider Incentive Compensation Program: Quality & Productivity.
• Provider Professional License, Certification and DEA Fees Reimbursement.

Why Join Sun River Health?

• Mission-Driven Work: Be part of a proud network of care that offers high-quality health and social support services to communities in need.
• Professional Growth: We provide opportunities for career advancement and professional development.
• Supportive Environment: Our culture promotes wellness, inclusivity, and recognition, ensuring a supportive and collaborative work environment.
• Community Impact: Make a difference in the lives of individuals and families by providing quality, affordable health care.

Join us at Sun River Health and be part of an award-winning network of care that has been serving our communities since 1975. We are always looking for skilled and dedicated professionals to join our team and help us continue our mission of providing quality health care to all.