Transitional Care Coordinator - Onsite in Charlotte County

Position Overview

• Location Type: Onsite
• Employment Type: Full Time
• Salary: (Not provided in the original text)
• Brief Description: The Transitional Care Coordinator is responsible for coordinating care for patients across the continuum to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. This role involves assessing patient needs, overcoming barriers, and evaluating results, working in facilities based out of Charlotte County, Florida.

Requirements

• Education: Bachelor’s degree from an accredited school of nursing and/or Allied Health program.
• Licensure: Currently licensed in the state of employment.
• Driver’s License: Valid driver’s license.
• Experience: At least 2-4 years’ experience in field and/or direct patient care.
• Knowledge of Regulations: Experience working with and/or good knowledge of federal, state, and local laws and regulatory guidelines governing home health and hospice operations.
• Relevant Experience: Experience in acute/ACO/post-acute care facility care coordination, discharge planning, social services, disease management, population health, home health, and/or post-acute care facilities.

Responsibilities

• Relationship Management: Cultivate and maintain professional relationships with clients, patients, and stakeholders by providing sensitive and respectful care in line with diversity standards and human dignity.
• Assessment & Care Planning: Conduct holistic assessments, prioritize patients based on need, and develop, implement, and revise care plans in collaboration with patients, families, and the healthcare team.
• Collaboration: Partner with healthcare providers, including physicians and hospital staff, to identify at-risk patients, reduce readmission risks, and facilitate smooth transitions across the healthcare continuum.
• Coordination & Education: Coordinate and educate program expectations with providers, payers, and families to ensure appropriate referrals and optimized clinical outcomes.
• Advocacy & Empowerment: Advocate for patient needs through effective communication and service coordination and promote patient self-management and wellness by empowering patients and families to make informed choices and build supportive care systems.
• Documentation & Compliance: Maintain accurate documentation, stay current on healthcare regulations and practices, and participate in team meetings and orientation activities to promote collaboration and continuous improvement.
• Other Duties: Perform other job duties as assigned.

Job Expectations

• Travel: Willing to travel up to 70% based on business needs.
• Hours: Willing to work additional or irregular hours as needed.
• Security: Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Physical Requirements: Must be able to sit and view a computer screen for extended periods of time.

Company Information

• (Not provided in the original text)

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