Care Continuum Partner

As a Care Continuum Partner at Lehigh Valley Health Network, you will coordinate care across inpatient, outpatient, and community settings for patients in eastern Pennsylvania. Working within our Healthcare & Medical Services department, you will develop individualized care plans, support smooth care transitions, and connect patients with needed resources. You will collaborate closely with nurses, physicians, and allied health professionals in a culture focused on excellence and community well-being, contributing to innovative, patient-centered care and improved outcomes across the continuum.

Responsibilities

• Serve as primary care continuum partner for assigned patients, coordinating services across inpatient, outpatient, and community settings
• Develop, implement, and update individualized care plans in collaboration with providers and interdisciplinary teams
• Facilitate safe, timely transitions of care, including discharge planning and follow-up appointments
• Engage patients and families through education, goal setting, and resource navigation to support self-management
• Monitor outcomes, track key metrics, and communicate progress to stakeholders
• Collaborate with nursing, physicians, social work, and ancillary services to remove barriers to care
• Ensure documentation accuracy in EHR and adherence to regulatory and network standards
• Identify high-risk patients and proactively coordinate interventions to reduce readmissions

Required Skills

• Care coordination
• Patient assessment
• Discharge planning
• Electronic health records (EHR) systems
• Interdisciplinary team collaboration
• Utilization management
• Population health management
• Data tracking and reporting
• Patient and family education
• Regulatory and compliance knowledge