Guthrie · 1 day ago
Transitional Care Mgmt Tech - Strategic Insurance Devt - Full Time
Sayre, PA
Full-time
Hybrid
Entry Level
2+ years expGuthrie is seeking a Transitional Care Management Tech to provide telephonic outreach to patients recently discharged from healthcare facilities. The role involves supporting patients with discharge plan adherence, medication management, and coordinating care with the healthcare team to facilitate a safe transition back to the community.
Health CareHospitalPersonal Health
Responsibilities
Accesses and navigates Team’s page and EMR system to identify recently discharged patients and review patient medical record
Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab
Sends notification to SNFs and requests notification by SNF to Care Coordination when patient is discharged
Performs patient outreach calls within the defined timeline (two call attempts within 2 business days) of hospital/SNF discharge
Performs review of discharge instructions with patient/caregiver and provides education/support for treatment regimen adherence and medication management to support self-management and independent living
Identifies potential care gaps and makes referrals as appropriate
Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed
Collaborates with the Transitional Care Nurses (LPN, RN) as needed for patient care needs
Notifies Primary Care Provider/Care Coordinator of any urgent needs or concerns
Schedules TCM face-to-face visit with PCP/AP
Arranges for tele visits for patients who are physically unable to come in to the PCP’s office as needed
Responds to TCM patient phone calls in a timely manner
Documents all patient encounters in the patient’s electronic medical record
Attends all required team/staff meetings
Qualification
Required
A minimum of two (2) years' experience in an ambulatory healthcare setting
Excellent interpersonal skills with a focus on expert patient care and communication
Sound clinical decision making
Good time management skills
High School graduate
Company
Guthrie
Health care
5001-10000 employees
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
Fidelis Care
2025-05-14Grant
Leadership Team
Edmund Sabanegh
President & Chief Executive Officer, The Guthrie Clinic
Brad Carvellas
SVP, Chief Digital Officer
Recent News
Central New York Business Journal
2026-01-03
2025-12-24
2025-09-23
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