Care Transition Specialist (Medicare) - Remote (PA/NJ/DE)

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

Summary

The Care Transition Specialist is responsible for supporting members as they transition from inpatient care to home or another care setting. This role ensures continuity of care, reduces avoidable readmissions, and promotes positive health outcomes through proactive outreach, education, and coordination of services.

Responsibilities

• Member Outreach & Engagement

• Contact members post-discharge to review discharge instructions, identify current needs, and escalate immediate needs to clinical team.

• Educate members on medication adherence, symptom monitoring, and follow-up appointments.

• Identify social determinants of health barriers and connect members to appropriate resources.

• Assists members with understanding their plan benefits and connects to member services.

• Care Coordination

• Assist with scheduling follow-up visits with network providers and specialists.

• Facilitate referrals to home health, durable medical equipment, and community-based services as needed.

• Collaborates with interdisciplinary team (nurse health coach and/or social workers) for consultation and referrals.

• Monitoring & Documentation

• Documents member outreach outcomes and barriers to care using health plan care management systems within scope of role.

• Document all interactions in compliance with organizational, regulatory, and NCQA standards.

• Monitor high-risk members and escalate concerns to clinical case managers as needed.

Requirements

• Bachelor's degree in health sciences, psychology, social work, or related field, nursing, public Health, or related field required.
• Medical Assistant certificate preferred.
• 1-2 years of experience in relevant work experience (healthcare, member-facing role such as case management and member outreach).
• Experience with transition of care calls offering post discharge support and patient engagement.
• Knowledge of managed care principles, discharge planning, and community resources.
• Strong communication and interpersonal skills.
• Excellent written and verbal communication skills.
• Ability to work independently and manage multiple priorities

Fully Remote:

This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.