Acute Care Transitions Engagement Specialist

JOB RESPONSIBILITIES:

1. Maintain daily organization of incoming censuses, call logs and zoning assignments for the Program Coaches. Review daily MMO census and assign members to Coaches based on Risk Tier stratification, visit type, geography and productivity targets. Productivity targets may vary throughout the course of the Program and staffing fluctuations.
2. This role is primarily telephonic for the course of the workday, in addition to research conducted via technological platforms (HIE research). Telephonic outreach targets may be up to 50-60 telephone calls to members daily, and 60-80 chart reviews/facility outreaches.
3. Update scheduling templates, calendars and visit assignments across multiple platforms, utilizing resources to determine member demographics.
4. Zone visits efficiently to minimize travel time and maximize Program productivity. Identify scheduling conflicts and cancellations and resolve them quickly to maintain workflow continuity.
5. Use efficiencies with technical navigation and data review, navigate Excel spreadsheets to sort, filter, track and prioritize the daily censuses and visit needs.
6. Enter and update member information and calls in the documentation platform with high accuracy and speed.
7. Utilize the HIE to verify admissions, discharges, transfers and clinical status changes.
8. Complete administrative support such as documentation cleanup, call attempts tracking, and census reconciliation.

1. Communicate clearly with accurate presentation to encourage member enrollment onto the Program. Make daily effort to engage members onto the Program at the earliest available timeframe, ideally upon census notification, prior to discharge.
2. Document all outreach efforts promptly. Maintain clean, organized scheduling records and ensure alignment across all platforms.
3. Identify key clinical details (diagnoses, discharge summaries, SNF status, care needs) that impact scheduling decisions and pivot scheduling scripting accordingly.
4. Communicate relevant clinical information to Nurse Coaches to support timely and appropriate outreach.
5. Follow agency protocols within scope when relaying information or preparing coaches for visits.
6. Maintain SNF outreach tracking, missed outreach follow‑up, and coordination of rescheduled visits. Communicate with post-acute staff when appropriate to promote member engagement.
7. Escalate complex cases to Supervisors for trouble shooting, with goal of promoting engagement and decreasing member abrasion.

Perform any other job-related instructions as requested.

Qualifications

Required:

• High school diploma
• 1 year of experience in customer service, sales, administrative support, or a related role
• Optimal proficiency with Microsoft Office applications, including Outlook and Excel
• Strong organizational, communication, and multi-tasking skills

Preferred:

• Experience in medical scheduling, care coordination, or clinical support roles.
• Background in healthcare, nursing support, or medical office operations.
• Familiarity with care management workflows or value‑based care programs.
• Experience working with multi‑provider or multi‑disciplinary teams.

At least 2 years college education