Care Transition Coordinator- Medical Assistant

MarillacHealth is hiring for a Care Transition Coordinator for our Grand Junction Colorado location. 

The ideal candidate for this position is an applicant who has worked as a Medical Assistant or LPN. 

Job Summary:    The primary duty of the ADT Assistant is to navigate patients through medical follow-up related to hospital admissions, discharges and transfers.  

Essential Functions:  

• Works in collaboration with multidisciplinary team members to coordinate healthcare services between hospitals, acute care facilities and community settings, to achieve positive outcomes with patient’s diagnosis. Reliable and punctual attendance is essential; expected to be at job as scheduled each scheduled day. 

• Collaborate with important team members (medical and behavior health providers, RNs and case management) for the purposes of education, risk stratification or identification of barriers to successful post-acute care planning by communicating necessary information as appropriate. 

• A patient navigation process, driven by needs is established and monitored along their diagnoses trajectory in collaboration with all team members. 

• Monitors and documents quality of care to ensure patient care plan goals are appropriate and achievable. Routinely assesses patient needs and makes appropriate referrals to other clinicians and providers. 

• Identifies actual and potential delays in service requests and treatment and communicates back to provider, pharmacy, and other involved staff as indicated. 

• Provides clinical support to prior authorization staff for medical necessity as needed. 

• Set up patients follow up appointments as needed. 

• Responsible for post discharge follow up within Transitional Care Management guidelines. 

• Telephone communication within 72 hours post discharge; including medication reconciliation and scheduling patient with provider based on visit acuity (7 days for high risk, 14 days for moderate risk). 

• Responsible for primary care patient follow-up after patient visit to Emergency Room 

• Required to check daily Admissions, Discharge and Transfers (ADTs) through QHN for patients who have visited the Emergency Room or Hospital. 

• Facilitate data collection and tracking of key data elements related to ADTs and appropriate follow-up. 

• Other job duties as assigned. 

Competencies:   

• Good Proficiency and navigation PC application included but not limited to MicroSoft suite of products and EMR systems  

• Ability to multitask while actively listening   

• Excellent keyboarding skills  

• Proper phone etiquette and articulate speech  

• Effective communication skills and the ability to build rapport with the patients, outside professionals and staff  

• Ability to work in a PCHM team model of care 

Required Education/Experience:  

• High school diploma or equivalent 

• 1+  years working in a clinical setting as Medical Assistant or CNA  

• Medical Terminology 

Preferred Education/ Experience: 

• Completion of a Certified Medical Assistant Program  

• Bilingual Spanish/English