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Transition of Care Coordinator I
Transition of Care Coordinator IClinica Sierra Vista • Bakersfield, CA, US
Transition of Care Coordinator I

Transition of Care Coordinator I

Clinica Sierra Vista • Bakersfield, CA, US
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  • [job_card.full_time]
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Job Description

Job Description

Clinica Sierra Vista is excited to be one of the largest Federally Qualified Health Centers in the Nation! We’re honored to serve the men and women of the fields. We also offer care and support to the inner city, the rural and isolated, those of low, moderate, and fixed incomes, and families from an array of cultural backgrounds who speak several languages. We don’t inquire about immigration status because we simply don’t need to know. If you come to us, we will treat you like any other patient.

As we grow our team, we are looking for individuals who believe the patient is always #1.

Why work for us?

  • Competitive pay which matches your abilities and experience
  • Health coverage for you and your family
  • Generous number of vacation days per year
  • A robust wellness plan and health club discounts
  • Continuing education assistance to grow and further your talents
  • 403(B) plan with company matching

Intrigued? We’d love to hear from you! Please review the job details below and then click “apply.”

We're looking for someone to join our team as a Transition to Care Coordinator I who facilitates proactive care for their patients, utilizes internal and external technology to support transitional functions, and leverages new information technology tools to bridge care gaps across different health care settings. The position emphasis will be on care coordination, communication, and collaboration with CSV Care Teams to provide timely access and optimal patient outcomes within the appropriate level of care.

Essential Functions :

Key result area

Objectives / Activities

  • Patient Outreach
  • Conduct patient outreach and education via telephone, text, and patient portal discharge from ER / hospital
  • Mentorship and leadership
  • Functions as a primary preceptor / mentor / trainer to new and tenured transition of care coordinators or quality care coordinators helping cover transition of care
  • Coordination of outpatient services
  • Coordinate PCP assignment by applying Four-Cut Method
  • Connect patients to health services according to their clinical needs and organizational quality standards
  • Liaise between community and health / social services
  • Screen patients for SDOH (Social Determinants of health) and other relevant screening questions during outreach
  • Provide patients community resources as appropriate, or resources from their health plans
  • Support quality improvement initiatives
  • Participate in PDSA’s and quality improvement projects that align with CSV priorities as directed
  • Provide feedback to Supervisor-Care Coordination
  • Regulatory Compliance & Accreditation
  • Support data collection / validation for regulatory reporting, and update internal / external reporting sites as needed
  • Assist with Health plan audits under the supervision of the Supervisor-Care Coordination / Manager of Quality and Population Health
  • Miscellaneous
  • Other duties as assigned
  • You'll be successful with the following qualifications :

  • One of the following. Existing employees in this role prior to June 2025 will be grandfathered in.
  • Medical Assistant certification or program completion WITH a high school diploma or GED and 3-4 years of healthcare experience in a primary care setting

  • Bachelor’s degree. Exposure to healthcare preferred.
  • 3. Knowledge of or experience with HEDIS and UDS preferred

    4. Basic Life Support from American Heart Association

    5. Experience in healthcare within Behavioral Health or addiction medicine, highly preferred

    Clinica Sierra Vista values human rights, goodwill, respect, inclusivity, equality, and recognizes that the organization derives its strength from a rich diversity of thoughts, ideas, and contributions. As leaders in healthcare industry, we aspire to be an employer of choice by promoting an organizational culture that reflects these core values. We seek to attract, develop, and retain a talented and dedicated workforce where people of diverse races, genders, religions, cultures, political affiliations and lifestyles thrive. Our goal is to create a welcoming and inclusive environment that empowers our employees to provide the highest level of service to our community of residents and businesses; they’re counting on us.

    Clinica Sierra Vista is an equal opportunity employer and strives to attract qualified applicants from all walks of life without regard to race, color, ethnicity, religion, national origin, age, sex, sexual orientation, gender identity, gender expression, marital status, ancestry, physical disability, mental disability, medical condition, genetic information, military and veteran status, or any other status protected under federal, state and / or local law. We aim to create an environment that celebrates and embraces the diversity of our workforce. We welcome you to join our team!

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