Transition Coach - Population Health

York, PA | Physician Practices | Tracking Code: 69491

Schedule & Location

Schedule: Full Time, Day/Evening (80 hours every 2 weeks) 

Location: 3421 Concord Rd. York, PA 17402

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.
 

NonEssential Accountabilities:

  1. Attends meetings as required.
  2. Performs other related duties as identified.
 

Common Expectations:

  1. Demonstrates a commitment to patients, visitors and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.
  2. Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
  3. Maintains the cleanliness of work areas as required.
  4. Maintains professional growth and development.
  5. Enters and/or retrieves data from established computer files using knowledge of various computer software applications.
  6. Provides outstanding service to all patients, providers, coworkers and customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
 

Qualifications

  • 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/TrainingCompletes 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
  • Skills:
    • Proficient communication skills including SBAR technique; Ability to effectively present clinical information to the care team; Proficient in navigating and entering information into an electronic health record; Models team work; Self-motivated and dependable; Able to work independently.
Marcus Schneider
Marcus Schneider
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)