Bay Aging is seeking a full-time Care Transition Coach for the Williamsburg/Peninsula area. This position will be remote work from home and you will conduct In-Person assessments in the Williamsburg, VA/Peninsula area for this role. The Care Transitions Coach is key to ensuring safe and effective transfers in the movement of patients across the care continuum, serving as the bridge between the professional staff in a care setting (e.g. hospital) and patient and/or family. All Coaches provide information and guidance to the patient and/or family for an effective care transition, to improve self-management skills and enhance patient-practitioner communication, by assisting patients with the development of a personal health record; practice medication management; schedule follow-up appointments with their physician/specialist; and learn to recognize symptoms that indicate their condition is worsening and how to appropriately respond.

Come share your talent with us. 98% of employees are proud to work at Bay Aging. Position reports to Director, Care Transitions. Salary $38,870/yr-$52,728/yr.

ESSENTIAL FUNCTIONS

• Coach may collaborate with physicians and inpatient clinical staff to identify appropriate patients for care transitions services, utilizing established criteria, daily hospital census reports and electronic medical records to facilitate in the daily referral process.

• Conducts daily hospital visits providing information and guidance to the admitted patient and/or family for acceptance to the care transitions program. Serves as a bridge between the patient and/or family and the assigned Field Coach; as time permits, conducts brief daily visits with patient until discharge.

• Reports all patient declines to appropriate clinical staff, case management, or care coordinator for follow-up; as time permits, revisits patient to encourage program participation.

• Coach will prioritize referrals and activities according to intensity, need, and required follow-up. Serves as a guide to the patient, coaching the patient in addressing critical issues and self-management tasks.

• Conducts hospital visits to those patients readmitted and previously coached to understand reasons/cause for the readmission.

• Conducts home visits (hospital visits if required), Skilled Nursing Facility (SNF) visits and follow-up phone calls within the guidelines of the Care Transitions Program

• Provides information and guidance to the patient and/or family for an effective care transition, provides guidance to improve self-management skills and enhanced patient practitioner communication. Serves as a bridge between professional staff in a care setting and the patient and/or family

• Evaluates aspects of each patient’s condition, diagnoses, medications and support systems to develop an individualized plan which will lead to a successful outcome in: medication self-management, use of a personal health record, appropriate primary care and specialist follow-up and knowledge of red flags.

• Maintains accurate and timely documentation on each referred patient as well as readmitted patients in database system including complete and concise journal entry notes.

SKILLS & EXPERIENCE

· Relies on extensive experience and judgment to plan and accomplish goals. Performs a wide variety of tasks

• Working knowledge of health care industry, caregiving, chronic disease management

• Knowledge and appreciation of cultural diversity and low literacy issues in care provision

• Decision making – handles all daily responsibilities relative to coaching a patient. Informs supervisor and works closely with supervisor with changes in patient’s condition

• Excellent verbal, written and computer literacy a must

• Ability to work in and away from the office, including in the evening and occasionally on weekends. Occasional overnight travel is required

• Ability to work methodically and patiently with limited resource and support

• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness/efficiency. Adapts to changing patient or organizational priorities

• Ability to work independently, while collaborating with other team members

• Ability to work with patient/families of all ages and in a variety of settings, including inpatient facility and patients’ homes presenting diverse physical conditions and social/cultural environments

MINIMUM QUALIFICATIONS

Requires a Bachelor’s degree preferably in Health Care Field, Care Coordination or at least 5

years of experience in Healthcare. Familiar with a wide variant of community resources. Must

possess a valid driver’s license, relevant certifications, etc.

Background check and drug screening required.

Additional: Must meet the requirements of the Sentara Healthcare Contract and complete at a

minimum, 20 – 25 billable home visits per month.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

An office-based position with some physical requirements (ability to lift 20 lbs, walking, and climbing stairs).Requires regular independent travel around the areas served by VAAACares. 50% of the essential functions of the position can be performed remotely.

FLSA Status: This is an exempt position.

Benefits Include: Medical, Dental and Vision Insurance, 401K Retirement Plan, Paid Annual Leave, Sick Leave and Holiday Leave, Employee Assistance Program, Life Insurance and Long Term Disability.

Bay Aging is an Equal Opportunity Employer. All applicants will be considered for employment without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, veteran or disability status. Bay Aging is committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. To request reasonable accommodation, contact MaDena DuChemin, Human Resource Manager at (804) 758-2396, Ext. 1228 or mduchemin@bayaging.or