LifeLong Medical Care

Care Transitions Liaison

3 weeks ago
# of Openings


Supporting Community Healthcare is a rewarding role and you can make a valuable contribution. LifeLong Medical Care is looking for a Care Transitions Liaison. Make a difference! Come join our team at LifeLong. This position works from our administrative office in Berkeley and reports to the Care Transitions Nurse Manager.


The Contra Costa Care Transitions Liaison (CTL) is responsible for providing technical, administrative and clerical support to the Care Transitions Manager. The CTL promotes excellent communication and coordination with hospital case management team members, external care facilities, Lifelong clinic staff, patients, and other care givers. The CTL acts independently with oversight from the Care Transitions nurse to implement the integrated transition plan developed by the nurse. The CTL registers new patients, makes follow up appointments in the clinics and communicates daily with hospital and nursing facility staff to coordinate care. This position requires efficient and effective coordination of patients through the health care system to ensure return to primary care in a safe and timely manner.


LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have 12 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an Equal Opportunity Employer.



We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan


  • Coordinates the integrated transition plan developed by the nurse.
  • Manages the complex interactions involved with the position including registering new patients, making follow-up appointments in the clinics and contacting hospital and nursing facility staff to coordinate care.
  • Enters, verifies and updates patient data in electronic health records system.
  • Coordinates movement through the continuum of care to facilitate return to primary care in a safe and timely manner.
  • Promotes excellent communication with hospital case management teams, care providers, LifeLong health center staff, patients, families and external care facilities.
  • Reporting as assigned.
  • Other duties as assigned by supervisor.


  • General knowledge of illnesses, current treatments and their physical and psychosocial sequelae.
  • Knowledge of alternate levels of care including criteria required for payment and applications processes.
  • Knowledge of applicable laws and regulations, government and insurance benefits, especially Medicare, Medi-Cal. Knowledge of available health care and community resources appropriate for populations served.
  • Knowledge of individual and family development over the life span and the influence of cultural and spiritual values in health care.
  • Knowledge of data collection techniques and methods of analyzing and reporting data
  • Excellent oral and written communication skills.
  • Excellent interpersonal skills and time management skills, ability to work effectively in a fast pace environment, with rapidly shifting priorities and competing demands.
  • Excellent organizational skills, excellent attention to detail and ability to provide timely follow up.
  • Excellent task prioritization skills.
  • Ability to work independently with a minimum of direction.  
  • Ability to exercise discretion and make independent judgments, seeking review when decisions represent significant departure from established guidelines
  • Ability to communicate in Spanish, or Asian language is helpful, but not required.
  • Proficient to advanced PC skills, word processing, spreadsheets and data base programs




Education & Experience

Associates or Bachelor’s Degree in Business/Health-Related field or equivalent experience in a health care setting required. (Bachelor’s degree preferred.) 

One or more years direct patient care or health education in an outpatient, skilled nursing, home health or related setting. Community Health Center experience preferred. Working knowledge of medical terminology. Experience in electronic medical records required. Knowledge of various health insurance plans preferred.





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