Responsibilities

The Transitional Care Coordinator will be responsible for coordinating care for patients across the continuum, utilizing high-level communication skills to assess and identify problems and outcomes, assisting patients with identifying and overcoming barriers, and evaluating the results. This role involves cultivating and maintaining professional relationships with clients, patients, and stakeholders, conducting holistic assessments, prioritizing patients based on need, and developing, implementing, and revising care plans in collaboration with patients, families, and the healthcare team. The Coordinator will also partner with healthcare providers, facilitate smooth transitions across the healthcare continuum, advocate for patient needs, maintain accurate documentation, and participate in team meetings and orientation activities to promote collaboration and continuous improvement.