Transitional Care Coordinator - CMA or LVN

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

At VillageMD, we're looking for a Transitional Care Coordinator to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results. We're creating care that's more accessible. Effective. Efficient. With solutions that are value-based, physician-driven and patient-centered. To accomplish this, we're looking for individuals who share our sense of excellence, are ready to embrace change, and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning. Could this be you? Integral to our Care Management team, the Transitional Care Coordinator is accountable for collaborating with the care team to consistently communicate and document high risk patient profiles to provider and practice care teams. As a new member of VillageMD, you’ll work closely with our multidisciplinary care team to connect the dots of collaborative patient care while incorporating patients’ personal health and lifestyle goals.

Outreach and engage patients whom are high risk, post-discharge, and/or requiring additional care management support, ensuring they have Primary Care Provider (PCP) follow up appointments scheduled and all care gaps are closed Collaborate with care team members and external vendors to support patient care (ie: receipt of durable medical equipment (DME) and home health services Request medical records from a variety of physicians and healthcare systems enabling the continuity of care for both PCPs and members of the interdisciplinary care team Outreach, screen and escalate patients to nursing and social work team members based on the unique needs of patients Assist nursing and social work team members with patient follow up, proving tools and resources at their direction Monitor stable patient populations at the direction of nursing and social work team members Address open care gaps with patients through collaborative relationships with patients, ensuring supporting adequate documentation is available with the patient’s medical record Coordinate with local community resources as needed to support both the physical and psychosocial needs of patients Collaborate with multi-disciplinary team members to provide best in class patient care and improved outcomes Participate in special initiatives at the direction of market leaders