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Atrius Health, an innovative healthcare leader, delivers an effective system of connected care for more than 690,000 adult and pediatric patients at 30 medical practice locations in eastern Massachusetts. Atrius Health’s 645 physicians and primary care providers, along with 420 additional clinicians, work in close collaboration with hospital partners, community specialists and skilled nursing facilities. Our vision is to transform care to improve lives. Atrius Health provides high-quality, patient-centered, coordinated, cost effective care to every patient we serve. By establishing a solid foundation of shared decision making, understanding and trust with each of its patients, Atrius Health enhances their health and enriches their lives. Atrius Health is part of Optum, a health services company focused on building the leading value-based care system in the country.

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*SUMMARY*

Provides outreach to patients following their discharge from treatment after receiving facility based care. The Transition Coordinator screens patients and/or caregivers for needs post discharge using protocols, standard work, and templates to identify patients in need of ongoing attention from their care team or other clinical resources. Identifies and addresses barriers to post discharge care, and documents outreach/contact/directives in the appropriate clinical systems. Communicates outcomes to appropriate care team members, Care Managers or others as needed. Performs a variety of activities that support the clinical, business and program related work of the Population Health Department. Collaborates with clinical and non-clinical staff across multiple departments and sites within the organization to ensure appropriate patient management.

This is a remote work from home position. Periodic onsite training and meetings may be required for the employee to attend.

EDUCATION/LICENSES/CERTIFICATIONS

High School Diploma or equivalent is required. Graduate of an Accredited Medical Assistant Program with certificate and completed externship, or similar/equivalent training is preferred.

Graduate of an accredited program for Licensed Practical Nurses and currently licensed as a LPN in the State of Massachusetts, Certified Nursing Assistant, or EMT preferred but are not required.

EXPERIENCE

Three (3) years’ relevant experience (i.e., making telephone calls to patients, reading and documenting in electronic medical records, or similar responsibilities) preferred.

SKILLS

Ability to understand medical records, er and hospital discharge plans.

Excellent customer service skills. Proficient in various software applications such as Microsoft Office Excel, Word and Outlook. Knowledge of Excel spreadsheets with ability to sort data.

Electronic Medical Record experience (particularly Epic) preferred. Excellent organizational, interpersonal, written and verbal communication skills. Effective problem-solving skills.

Must consistently exercise sound decision-making skills to apply protocols and policies correctly.

Must have ability to multi-task, prioritizing daily workload and seek assistance when necessary.

Demonstrated ability to learn new processes quickly. Ability to engage in telephone contact with patients within an ambulatory practice setting.

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Atrius Health is committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of Atrius Health will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital/domestic partner status, parental status, sexual orientation and gender identity and/or expression, or other dimensions of diversity.

*Benefits Include:*

• Up to 8% company retirement contribution

• Generous Paid Time Off

• 10 paid holidays

• Paid professional development

• Generous health and welfare benefit package

**Job:** **Practice Support Staff*

**Organization:** **Case Management*

**Title:** *Transition Coordinator - Norwood - Case Management - Hybird - FT*

**Location:** *Norwood MA*

**Requisition ID:** *125551*