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Summary

The Transitional Care Management Tech-CA (TCMT) provides telephonic outreach to patients that have been discharged from a hospital or Skilled Nursing Facility within 2 business days of discharge. TCMT may also utilize other means of outreach communication such as Patient Portal or letter as appropriate. The TCMT provides patient support for discharge plan adherence, treatment regimen adherence and medication management, education to patient and/or family members to support self-management and independent living and communicate with other members of the patient’s care team to ensure care coordination and a safe transition back to community. The TCMT schedules a TCM face-to-face visit with the Primary Care Provider or Advanced Practitioner and assists with scheduling other specialists’ visits as indicated. The TCMT identifies available community services and health resources and facilitates access to care and services available to patient/family when needed. TCMT notifies PCP and/or Care Coordinator of any urgent patient needs. Collaborate with the Care Coordination team to provide handoff and ongoing support for patient needs as identified.

Experience

A minimum of two (2) years’ experience in an ambulatory healthcare setting. Excellent interpersonal skills with a focus on expert patient care and communication, sound clinical decision making, and good time management skills

Education

High School graduate.

Essential Functions

+ Accesses and navigates Team’s page and EMR system to identify recently discharged patients and review patient medical record.

+ Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab.

+ Sends notification to SNFs and requests notification by SNF to Care Coordination when patient is discharged

+ Performs patient outreach calls within the defined timeline (two call attempts within 2 business days) of hospital/SNF discharge.

+ Performs review of discharge instructions with patient/caregiver and provides education/support for treatment regimen adherence and medication management to support self-management and independent living.

+ Identifies potential care gaps and makes referrals as appropriate.

+ Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed.

+ Collaborates with the Transitional Care Nurses (LPN, RN) as needed for patient care needs.

+ Notifies Primary Care Provider/Care Coordinator of any urgent needs or concerns

+ Schedules TCM face-to-face visit with PCP/AP

+ Arranges for tele visits for patients who are physically unable to come in to the PCP’s office as needed.

+ Responds to TCM patient phone calls in a timely manner.

+ Documents all patient encounters in the patient’s electronic medical record

+ Attends all required team/staff meetings

Other Duties

Travel for this position is sometime required.

+ The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures.

+ It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.

After successful completion of their probation period there is a hybrid work opportunity.

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.