Directly responsible for providing supportive care transition services to patients aligned to the health system’s value-based care programs in collaboration with clinical and administrative stakeholders across the organization. Serves as part of a multi-disciplinary team toconnect with our managed patient populations and their families, ensuring the necessary resources are in place to timely, safely, and effective ly navigate the patient between each site of care until the patient is successfully discharged to home.

Essential Functions
• Possesses a strong understanding of medical terminology and understands healthcare operations, patient engagement, physician
relations and all other healthcare related issues.
• Takes initiative to develop knowledge, skills, and abilities to perform at a high level in the care transition navigation role, including
staying abreast of related care transition management news, documentation, and literature.
• Ensures compliance with all necessary risk management programs, corporate quality initiatives, and other corporate objectives.
• Partners with various healthcare entities and physician practices to foster integrated relationships with patients, families, and
caregivers to facilitate streamlined patient transitions across the continuum of care.
• Assists patients and caregivers in navigating care services post-hospitalization, including development of patient-tailored post-acute
care plans and routine patient monitoring to ensure plan adherence.
• Engages with patients using strong communication skills and utilizes patient feedback to identify current service needs and anticipate
future service needs using a patient-first philosophy.
• Distributes approved educational materials and other care transition resources to patients and caregivers to effectively remove social
determinants of health barriers with the goal of preventing readmissions and other avoidable care events.
• Advocates for patient needs by proactively identifying barriers to treatment plans and ensuring patients have access to needed
prescriptions, durable medical equipment, and other care services, as necessary.
• Collaborates with the population health and value-based care departmental nursing team and relevant network aligned physician
partners to share, discuss, and modify care transition plans, as needed.
• Maintains a high level of proficiency with organizational informational systems, including ELLiE Healthy Planet modules, to ensure
care transition support for our covered populations is efficient, timely, and effective.
• Performs other duties as assigned to support the health system’s overall population health and value-based care team objectives.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state
and local standards.
• Maintains compliance with all Orlando Health policies and procedures.

Other Related Functions
• Works comfortably in teams as a participant and facilitator, including temporary teams for project-based initiatives.
• Possesses the ability to prioritize and work independently in addition to being an integral part of the care team.
• Communicates effectively through all forms of media and leverages critical thinking skills to effectively solve problems.
• Documents work efforts in an organized and accessible fashion while respecting confidentiality/privacy standards.
• Contributes to environment of psychological safety where ideas are welcomed, considered, and appreciated.

Education/Training
High school diploma or GED required.

Licensure/Certification
None.

Experience
One (1) year experience as a Medical Assistant, Paramedic, Emergency Medical Technician, Military Allied Health Professional, Nursing Assistant or related health care role in value-based care or physician offices required.