Transitional Care Coordinator ED

Perform screenings, education, and navigation for health-related social needs

Document care coordination services and referrals in a timely and accurate manner, in the patient electronic health record (EHR) and any other platforms (e.g. Unite Us) as requested

Assist patients with transportation needs to support timely and safe discharges and continuity of care at follow up appointments

Coordinate/schedule follow up appointments for patients to support transition of care goals

Conduct patient phone outreach post-discharge to support transitions of care

Facilitate referrals of patients to Wyckoff programs that can support the patient’s treatment goals and/or social needs

Provide support and facilitate access to resources to ED-based programs such as the Opioid Overdose Prevention Program

Maintain a tracker of services provided and patients who were assisted, and provide regular reports and summaries as requested by supervisor and the 1115 Waiver leadership team

Collaborate with other departments (e.g. Social Work, Population Health) to address patient needs holistically and comprehensively

Demonstrate excellent customer service, professionalism, and sensitivity toward patients and coworkers

Participate in regular huddles and interdisciplinary team meetings

Attend trainings and orientations as required, including virtual, on-site and off-site

Other related duties as assigned

Formal Education

and Job-Related

• Experience. High School Diploma/GED.
• Experience working with electronic health records (EHRs) preferred.
• Salary - $55,000 Annually