Job Description

Join to apply for the Care Transitions Health Coach MCO role at The Span Center . Job Overview Conducts Care Transitions Interventions for eligible patients to prevent hospital readmissions. These interventions emphasize empowering patients to manage their chronic conditions through education, self‑advocacy, and guidance on navigating complex healthcare systems. Ensures patients are informed about available support and services through Managed Care Organizations (MCO). Performs related duties as required. Supervision Performs work under the direct supervision of the Care Transitions Program Manager. Duties/Responsibilities Receives referrals for the Care Transitions program from the Managed Care Organization (MCO). Facilitate effective care transitions by providing guidance and support to patients and their families. Conduct effective in‑person and telephonic visits that promote patient self‑care management, utilizing coaching tools like the Personal Health Record. Identify medication discrepancies and assist patients in reconciling issues with their physician or pharmacist. Educate and coach patients to recognize signs and symptoms of worsening conditions and take appropriate actions. Encourage patients to keep scheduled appointments with their primary care physician and other necessary healthcare professionals; arrange transportation when appropriate. Use designated online platforms to enter client information and interactions related to Care Transitions, communicating with the MCO Care Manager as needed. Provide regular reports and documentation for billing and data collection purposes. Actively engage in professional development programs and monthly supervision meetings. Attend meetings and training sessions to enhance knowledge and skills. Counsel individuals, families, and clients to resolve issues related to human service delivery and promote self‑advocacy. Participate in advocacy efforts to support diverse community needs. Support opportunities for community volunteers to engage with relevant aspects of the department or program. Perform additional duties as assigned. Knowledge, Skills, and Abilities Understanding of laws and regulations related to patient care and transitions. Familiarity with care transition models and best practices. Knowledge of local healthcare services, support groups, and resources. Strong verbal and written communication skills to interact effectively with patients, families, and healthcare providers. Ability to assess situations and develop effective solutions for patient care transitions. Proficiency in managing multiple cases and maintaining accurate records. Ability to understand and respond to the emotional needs of patients and families during transitions. Capacity to work effectively with interdisciplinary teams and community partners. Flexibility to adjust to changing patient needs and healthcare environments. Ability to conduct interviews, analyze facts, and exercise sound judgment. Ability to prepare reports and maintain case records using computer automation technology. Excellent interpersonal skills. Must be able to travel. Valid driver's license required. Education and Experience A Master of Social Work (MSW) or a graduate degree is a plus. A Bachelor’s Degree in a health‑related field, such as nursing or social work, is required, along with at least two years of relevant experience. Physical Requirements Prolonged periods sitting at a desk and working on a computer. Prolonged periods of sitting behind a vehicle for travel time within the planning district. Must be able to lift up to 15 pounds at times. The Span Center is a trauma‑informed, person‑centered agency dedicated to fostering a safe and supportive environment for both our employees and the communities we serve. The Span Center prohibits discrimination on the basis of race, color, religion, national origin, sex, pregnancy, childbirth or related medical conditions, age, marital status, disability, sexual orientation, gender identity, genetics, political affiliation, or military status in the recruitment, selection, and hiring of its workforce. #J-18808-Ljbffr The Span Center

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