This role involves helping members navigate the healthcare system in a better and safer way. The Transitions of Care (TOC) Team supports members who are newly discharged from the hospital. As a TOC Associate, your goal will be to support members in safely recovering at home and to prevent hospital readmissions. Calling patients to check in after discharge to see how they are doing, and that they have received the assistance they need. Work with affiliated vendors to coordinate services and care for members, including transportation, DME, meals, home health care, and more as appropriate. Assisting with scheduling of post-discharge PCP and Specialist visits. Collaborate with patients, providers, and caregivers to ensure a positive outcome. Working hand in hand with the other members of the TOC team to address patient needs towards team-based goals, including interdisciplinary huddles. Participating in and assisting with pilot programs. Coordinating with medical providers and facilities to access necessary discharge records. Following escalation processes to the clinical team to ensure patients get needed evaluation and care.