Responsible for administrative activities of the Medical Directors in Transitional Long-term Care (TLC) and Complex Care Programs (CCP). Coordinates clinical care and acts as a primary liaison for families between the major disciplines involved in the treatment of complex care patients. Facilitates the coordination of care and community resources for maintaining health, addressing illness and supporting associated life problems for this targeted group of patients whose needs represent high social and clinical risk.

1. Provides administrative support to CCP Medical Director, TLC Medical Director, and the complex care team.



2. Assesses program needs and identifies opportunities for improvement, including special projects, using continuous performance review and feedback from providers, staff, patient advocates, and families to develop and implement program changes in collaboration with the Medical Directors.



3. Maintains knowledge of and follows complex care and disease-specific scheduling protocols as advised by the care team in alignment with AAP guidelines to streamline and coordinate consistent care for each patient.



4. Coordinates all outpatient service referrals with families, from Care Team members, and organizes comprehensive discharge planning meetings for on-going care, which includes the family, multidisciplinary care teams and community agencies.



5. Develops and maintains positive working relationships with community resource organizations to benefit patient care coordination.



6. Acts as liaison with various community agencies, including durable medical companies, to facilitate equipment and other service requests for patients and their families.



7. Remains current on patient financial eligibility status and obtains prior approvals/authorizations for services as needed.



8. Oversees the organization and evaluation of the materials and patient education information for the outpatient clinics, collaborating with the Reach Out and Read (ROR) Chapter.



9. Coordinates and assists in research activities such as medication studies for patient population.



10. Works collaboratively with Director of the TLC program on research projects involving standardization of protocols for the New England (NE) Fun Collaborative, collects and enters data from the Vermont Oxford Network (VON) database, and completes data entry in RedCap for high risk patients in Neonatology and Complex Care.



11. Supports department in tracking licenses, dues, memberships and submits for reimbursement including travel. Orders office supplies, business cards and catering needs.



12. Performs other duties as required or assigned.

• Bachelor’s degree with 2 years or experience, or the equivalent in education and experience required.



• Excellent written, verbal and interpersonal communication skills and the ability to work independently, assess priorities, and organize workload required.



• Ability to work with minimal supervision as a team member in a self-directed environment, adhering to the mission and values of D-H & CHaD.

• None