Transition of Care Partner

Job Summary

Sun River Health provides comprehensive primary, preventive, and behavioral health services to all who seek care, regardless of insurance status or ability to pay. We serve communities across the Hudson Valley and seek a full‑time Transition of Care Coordinator in Peekskill, NY.

Pay & Sign‑On Bonus

• Pay: $23.00 - $25.24 per hour
• $1,500 Sign‑On Bonus*

Responsibilities

• Facilitate bidirectional information exchange with hospital and primary care providers.
• Perform workout rounds to hospitals as indicated to meet with patients and discharge planners.
• Conduct outreach follow‑up for patients recently discharged from hospitals, ERs, postpartum units, skilled nursing, and rehabilitation facilities.
• Arrange appointments, refer patients to appropriate agencies, specialty providers, and community resources.
• Obtain hospital records and ensure they are received and filed in eCw; identify barriers to interdisciplinary collaboration and propose solutions.
• Identify needed follow‑up on tests and document via appropriate EMR.
• Coordinate patient documentation (discharge papers, medication lists, visit summaries, consultant reports, medical record releases, consent).
• Manage an outreach schedule for patient follow‑up and appointment setting, coordinating care with internal and external stakeholders.
• Assist patients in overcoming barriers to obtaining necessary appointments and medical care.
• Screen patients for factors influencing social determinants of health and initiate referrals using appropriate resources.
• Consult with the transition‑of‑care team, seek clarification when needed, and flag encounters requiring complex care or triage.
• Participate in the development and implementation of patients' Transition of Care Plan with nursing staff to meet established goals.
• Refer and maintain continuity of care for high‑risk patients, collaborating with licensed clinical staff and monitoring treatment plans.

Qualifications

• High school diploma or equivalent.
• Minimum of one year of relevant experience.

Equal Employment Opportunity

Sun River Health provides equal employment opportunities to all qualified individuals without regard to race, creed, color, religion, national origin, age, sex, marital status, sexual preference, or non‑disqualifying physical or mental handicap or disability in each aspect of the human resources function.

Americans with Disabilities Act

Applicants and employees who are disabled must be able to perform essential job functions either unaided or with reasonable accommodation. The organization determines reasonable accommodation on a case‑by‑case basis in accordance with applicable law.

Benefits

• Medical, Dental, and Vision Insurance.
• Life and Disability Coverage.
• Retirement Savings Plan.
• Commuter and Transit Benefits.
• Employee Assistance Program (EAP).
• Employee Discount Program.
• Provider Incentive Compensation Program.
• Provider Professional License, Certification, and DEA Fees Reimbursement.