Lifetime Care Care Transitions Coach Full or Part Time in Newark, New York

Description The Care Transition Coach (CTC) is responsible for a patient’s safe transition from hospital or other in-patient facility to home. A CTC determines patient eligibility based on medical condition and then implements the Care Transitions Program. The intervention is geared toward patient self management of chronic diseases via teaching/modeling, self advocacy, and education on how to negotiate complex health care systems. This position will be based at Newark Wayne and Clifton Springs Hospitals.

Essential Responsibilities/Accountabilities

  • Assesses patient health literacy, understanding of diagnosis and medication regime.

  • Determines patient eligibility for Care Transitions program through a review of medical record, input from physician or other medical personnel and patient interview.

  • Conducts effective in home visits using the prescribed Care Transition Program focusing on avoiding re-hospitalization

  • Provides telephone visit follow up that promotes patient self-care management, utilizing Coaching tools such as Personal Health Record.

  • Completes a medication reconciliation identifying any medication discrepancies and assisting patient in resolving discrepancy with physician or pharmacist.

  • Teaches/coaches patient to recognize signs and symptoms of worsening disease and take appropriate measures.

  • Facilitates completion of Advanced Directives.

  • Ensures that patients schedule/attend appointments with primary care physician within established time frames.

  • Demonstrates, develops and maintains positive professional relationships within a hospital setting and with outside service providers.

  • Interprets social/financial factors in the patient situation that may have bearing on the patient’s progress.

  • Communicates and coordinates with interdisciplinary team assuring care plan compliance.

  • Coordinates appropriate community based referrals to insure patient safety and progress towards wellness prior to discharge including referrals to insurance care management programs.

  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct

  • Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures

  • Regular and reliable attendance is expected and required

  • Performs other functions as assigned by management


  • Bachelor’s Degree in Social Work or a related field with a minimum of five years of experience in a health related setting that includes a clinical background.

  • Successful completion of the Care Transitions Intervention training program is required.

  • Understanding of Electronic Medical Records.

  • Experience in reviewing medical records and developing implementation plans for patients/clients.

  • Demonstrates strong communication (both written and verbal), interpersonal, organizational, and time management skills.

  • Ability to deal effectively with internal and external audiences at all levels.

  • Excellent Computer skills.

  • Ability to stay flexible.

  • Strong attention to detail.

  • Requires pre-employment physical exam as required by NYS Dept. of Health.

  • Must have ability to travel.

Physical Requirements

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Requisition Number: 16-0592

Post Date: 8/8/2016

Title: Care Transitions Coach Full or Part Time

Job Type: Full Time

City: Newark

State: NY