Hospital Follow Up Specialist

Department: Community Health Team

Reports To: Director of Community Health Integration

Classification: Exempt – Salaried

JOB SUMMARY: The Hospital Follow Up Specialist is a member of the Community Health Team and is responsible for managing workflows to coordinate the care of patients discharged from inpatient and emergency department (ED) care to reduce the likelihood that they need further hospitalization and to improve their health outcomes.


  1. Actively participate in the development, implementation, and continual evolution of new workflows for the Hospital Follow Up Care Coordination Program.
  2. Receives secure patient lists from hospitals of all admits to inpatient and ED.
    1. Filters lists based on patient eligibility for discharge care coordination.
    2. Enter patient information and other documentation into software systems to aid in care coordination.
    3. Follow workflows generated by software.
  3. Attends and contributes to hospital rounds and discharge planning meetings.
  4. Conducts social determinants of health screenings and utilizes other assessment tools.
  5. Works collaboratively with partner organizations to coordinate follow up care (i.e. Home Health and Hospice).
    1. Refer to social services for supports
  6. Schedule follow up office visits
  7. Conducts follow- up calls to patients
    1. Review discharge plan as needed
    2. Other workflow actions
  8. Provide medication reconciliation for patients
  9. Work within EMR to record actions needed and other documentation to prepare for office visits.
    1. Ensure proper documents available
  10. Refer to other members of CHT for complex cases that need further care coordination.

KNOWLEDGE AND EXPERIENCE: (Minimum education, experience, technical and communication skill levels and licenses/certificates normally required to perform the duties of this position.)

  1. Required skills, knowledge and abilities:
    1. Strong organizational skills and detail orientation
    2. Excellent interpersonal skills and compassionate approach to care
    3. Curious and diligent in learning about patient’s needs/ situation(s)
    4. Proficient computer skills, including excel
    5. Ability to work with and organize data
    6. Excellent communication and collaboration skills
    7. Proven critical thinking and problem-solving skills
    8. Ability to work independently and self-direct work
    9. Self-driven learner
    10. Takes initiative to go above and beyond the minimum expected
    11. Flexible and able to set boundaries
  2. Education: LPN Licensure
  3. Prior Experience: Three years of working in a health care setting. Additional experience working in social services to support individuals with complex needs preferred. Experience working with data.

WORKING CONDITIONS: (Typical working conditions associated with this type of work and environmental hazards, if any, that may be encountered in performing the duties of this position.)

Internal – Machinery or Equipment Used:  Telephone, computer, printers, and hand-held communication device.

External – Work in community in a variety of settings. Travel is required.

PHYSICAL DEMANDS: (The physical effort generally associated with this position.)




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