Care Transitions Coach

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Care Transitions Coach to function as a facilitator of interdisciplinary collaboration and care continuity from hospital to home, coaching the member and caregiver to play an active and informed role in post discharge recovery. The Care Transitions Coach position is primarily located in the hospital and in the field.

The essential duties & responsibilities will include the following:

• Maintain model fidelity in transition support services, generally based upon the established principles of care transition management.
• Work on-site at partner hospitals, to identify and enroll members into the Care Transition program.
• Coordinate with HPSM utilization review staff by forwarding inpatient facesheets/treatment authorization requests for processing. Request additional information from hospital staff only as necessary and as defined by HPSM criteria.
• Apply essential tenets of care transition models including medication self-management, use of a patient-centered personal health record, primary care and specialist follow up, and knowledge of red flags, with an emphasis on members establishing personal goal(s).
• Follow member through continuum of care (hospitalization/SNF) with home and facility visits, and perform follow up telephone calls.
• Contact healthcare provider(s)/care manager(s) to establish documentation of transitional care plan.
• Assist members with appointments for specialists, educational classes, and transportation.
• Assist with medication reconciliation in collaboration with attending physician and/or Primary Care Physician.
• Coach members and caregivers on how to access available community resources and interact with healthcare providers as part of their healthcare team.
• Coordinate warm hand-off to Care Management for necessary involvement of continuation of care and services.
• Track coach-related metrics and report on intervention progress.

Requirements

Education and Experience: Bachelor’s degree in nursing or related health/social services field preferred. Five (5) years of relevant work experience in a health care or managed care setting including at least one year in care transition work. Customer service, patient/peer coaching, medical patient interaction, and community relations.

Knowledge of: Case management principles and practices. Medicare and Medi-Cal programs/benefits. The complexities of working with the elderly and disabled populations. Community resources. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.

Ability to: Work efficiently with multidisciplinary team. Gain consensus on resolution of problems. Provide excellent customer service. Effectively communicate both verbally and in writing. Utilize personal computers and Microsoft Office products (Word, Excel, Access, and Outlook). Work and problem solve independently in most instances: require limited supervision.

Other Requirement: The incumbent must have own vehicle and valid driver’s license with proof of insurance in conformity with state law minimums. Bilingual skills (Spanish, Tagalog or Chinese) highly preferred.

Compensation & Benefits

Starting Compensation Range: Depends on experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost.  Employee pays a small portion of the dependent premiums for medical and dental benefits.  Additional HPSM benefits include fully paid vision, life, AD&D and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.