PRIMARY FUNCTION

The Transition of Care Specialist supports patients following hospital, emergency department, or other healthcare discharges by completing telephone outreach activities and assisting with care coordination. This position conducts outreach for low- and moderate-risk patients, schedules follow-up appointments, and documents activities in the electronic health record (EHR). The Transition of Care Specialist works closely with Community Health Workers and other care team members to ensure patients receive timely follow-up care and support.

PRINCIPAL DUTIES

Transition of Care Outreach Conduct post-discharge outreach to assigned low- and moderate-risk patients using telephone and approved patient communication platforms, following organizational protocols. Utilize patient communication platforms to send targeted broadcast messages and invitations to identified recipients for follow-up care, appointments, services, and other approved outreach initiatives. Document all outreach attempts, communications, and patient interactions accurately and in a timely manner in the EHR and/or designated communication platform. Assist patients with scheduling follow-up appointments, reinforcing the importance of follow-up care and adherence to discharge instructions. Identify barriers, unmet needs, or concerns and escalate patients to Community Health Workers or other appropriate care team members. Maintain assigned productivity, outreach, and documentation standards while ensuring communications are timely, professional, and patient-centered. General Participates as a member of the Patient Experience team. Maintains communication with care team members through accurate and timely EHR documentation. Assists with other duties or projects as assigned by supervisor. Supports organizational goals related to quality improvement, care coordination, and population health. Protects the confidentiality of patient information at all times. Assists with workflow improvement activities as assigned.

JOB REQUIREMENTS

Minimum Education High School Diploma or GED required. Minimum Work Experience One year of experience in healthcare, customer service, call center, medical office, or related setting preferred, but not required. Required License N/A Qualifications Successful applicants will be organized, dependable, and detail-oriented with a professional demeanor. Position requires strong verbal and written communication skills, basic computer skills with demonstrated proficiency in Microsoft Excel, and the ability to work independently while maintaining accuracy and productivity. Knowledge of patient confidentiality requirements and strong customer service orientation is required. Preferred qualifications include experience with electronic health records, care coordination activities, population health programs, or healthcare technology platforms.