York, PA | Physician Practices | Tracking Code: 88901

Transition Coach

Christopher Mamay
Christopher Mamay
Senior Talent Acquisition Consultant
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September 28 In-Person Hiring Events
Various Times
WellSpan Chambersburg Hospital, Chambersburg
WellSpan Ephrata Community Hospital, Ephrata
WellSpan Medical Group
Visiting Nurses Association (VNA)
Positions in Behavioral Health, Clerical and Administrative, Information Systems & Technical Support, Leadership, non-clinical Professional, Nursing, Nursing Support, Physician Practices, Professional, Rehabilitation and Services & Trades.
In-Person Hiring Events -
Various Locations and Dates

Location: 3421 Concord Road York, PA 17402

Schedule: Days/Evening

Job Description

Under the general supervision of the Population Health Care Management team leadership, provides transition coaching services to patients. Functions as a facilitator of care continuity across care settings, coaching the patient and caregiver to play an active and informed role in care plan execution. Helps patients manage their chronic diseases. Assists in the care of patients, and instructs patients and their families in appropriate care, as directed by their provider. Focuses on skill transfer beginning during the home visit and continuing throughout the 30-day relationship. The Transition Coach provides practice and guidance to the patient/caregiver for effective care transitions, improved self-management skills and enhanced patient-practitioner communication.


Duties and Responsibilities

  1. Provides support to patients during the transition of care via appointment coordination and navigation of the health system.
  2. Communicates and shares information with providers and the Ambulatory CCT members on issues and concerns such as transition of care between hospital, skilled nursing facility, rehab and home care.
  3. Refers to appropriate care management service for longer term coaching and support utilizing the established referral processes.
  4. Addresses and mitigates patient social determinants of health needs that could negatively impact care plan follow through.
  5. Uses Motivational Interviewing techniques to engage patients in self-management skills.
  6. Assists patients with instruction and health literacy through teach back of any new medications, transition instructions and equipment. Provides health care information materials and reviews with patient and or family members as directed by providers.
  7. Maintains the patient’s records to ensure an accuracy of the patient’s medical treatment. Documents in the patient record under the direction and supervision of the care provider.

Required Experience/Education

  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • 1 - 2 years
  • Minimum Education:
    • Post High School Vocational/Specialized Training
  • Required Certification:
    • Current LPN license in PA; Basic Life Support (BLS) certification
    • Req Courses/Training completes all required education programs and competency testing needed to perform at an advanced level; medical terminology
  • Physical Demands:
    • Prolonged periods of standing/walking
    • Occasional sedentary work
    • Lifts supplies, files and equipment
    • Occasionally lifts, positions, pushes and/or transfers patients
    • Periodic reaching, stooping, bending, kneeling, crouching

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