Transition of Care Associate – Licensed Practical Nurse

• Complete post-discharge questionnaire, which may be market specific
• Providing comprehensive discharge planning
• Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications
• Benefit education
• Provides clinical assistance to determine appropriate services and supports due to member's health needs (including but not limited to: Prior Authorizations, Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports)
• Evaluation of health and social indicators
• Identifies and engages barriers to achieving optimal member health
• Uses discretion to apply strategies to reduce member risk
• Presents cases at case conferences for multidisciplinary focus to benefit overall member management
• Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member's condition(s) and abilities to self-manage
• Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up
• Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel
• Updates the Care Plan for any change in condition or behavioral health status
• Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines
• Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions
• Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community
• Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions

• 2+ years’ work experience as a Licensed Practical Nurse (LPN)
• Candidate must be a Licensed Practical Nurse (LPN) with active and unrestricted status
• Discharge planning experience
• Advanced proficiency in Microsoft Word, Excel, and Outlook
• Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care
• Effective verbal and written communication skills
• Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses
• High School Diploma OR Equivalent Experience (REQUIRED)
• Associate's Degree (PREFERRED)
• Active and unrestricted Licensed Practical Nurse (LPN) license

Bilingual

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access