Care Transition Coordinator

Corterra of Wichita; Wichita (KS); On-site; USD 45,000 - 65,000; Full time

Job summary

Corterra of Wichita in Kansas seeks a compassionate Care Transition Coordinator to support safe patient intake and discharge planning within the interdisciplinary team. You will coordinate referrals to skilled nursing facilities, residential settings, and home health agencies, while communicating with families and providers to ensure smooth transitions.

This role emphasizes post-discharge follow-up, accurate documentation, HIPAA compliance, and effective collaboration with hospital staff.

Qualifications

• BSW or MSW preferred, but not required.
• Current students pursuing a degree in Social Work, Psychology, Human Services, Healthcare, or a related field are encouraged to apply.
• Acute Care Discharge Planner, Social Services Designees (SSD) or candidates with experience in long-term care, behavioral health, case management, discharge planning, or healthcare are encouraged to apply.
• Previous experience working with older adults, behavioral health patients, skilled nursing facilities, assisted living communities, or community resources preferred.
• BLS & First Aid certification required
• Must complete all required Hospital competencies and training.

Responsibilities

• Assists Director of Admissions with successful intake of new patients
• Assists the Social Services Director with timely and efficient discharge planning for hospitalized patients.
• Initiates and follows up on referrals to skilled nursing facilities, assisted living communities, residential settings, home health agencies, outpatient providers, and other appropriate community resources.
• Contacts facilities and community providers to determine placement availability and obtain information necessary to coordinate patient discharge.
• Assists with gathering and sending required clinical documentation for referrals and placement.
• Tracks pending referrals and follows up with facilities regarding acceptance, denial, or additional information needed.
• Communicates discharge planning updates to the Social Services Director and interdisciplinary treatment team.
• Assists with communication between patients, families/responsible parties, nursing staff, providers, and community agencies regarding discharge needs.
• Helps coordinate transportation, follow-up appointments, community resources, and other discharge-related services as directed.
• Conducts post-discharge follow-up calls with patients, families, facilities, or other responsible parties to confirm successful transition and identify concerns requiring additional follow-up.
• Documents post-discharge contacts and communicates identified concerns to the appropriate Hospital team member.
• Maintains an organized system for tracking anticipated discharges, referrals, placement status, barriers to discharge, and follow-up needs.
• Assists with obtaining information regarding patient psychosocial needs and available community resources.
• Participates in treatment team or interdisciplinary meetings as requested.
• Completes documentation and progress notes within the scope of the position and according to Hospital policy.
• Maintains patient confidentiality and complies with HIPAA, Hospital policies, and applicable state and federal requirements.
• Maintains professional communication with patients, families, referral sources, facilities, and community partners.
• Other duties as assigned

Job description

We are seeking a dynamic and compassionate Care Transition Coordinator to join our team! In this vital role, you will work with the interdisciplinary treatment team with coordinating safe, timely, and effective patient intake and discharges. The primary focus of this position is assisting with the intake of new patients, discharge planning for patients who have successfully completed the program, coordinating referrals and placement, communicating with families and community providers, and conducting post-discharge follow-up.

Qualifications

Education & Experience

• BSW or Master’s Degree in Social Work (MSW) preferred, but not required.
• Current students pursuing a degree in Social Work, Psychology, Human Services, Healthcare, or a related field are encouraged to apply.
• Acute Care Discharge Planner, Social Services Designees (SSD) or candidates with experience in long-term care, behavioral health, case management, discharge planning, or healthcare are encouraged to apply.
• Previous experience working with older adults, behavioral health patients, skilled nursing facilities, assisted living communities, or community resources preferred.
• BLS & First Aid certification required
• Must complete all required Hospital competencies and training.

Essential Functions & Responsibilities

• Assists Director of Admissions with successful intake of new patients
• Assists the Social Services Director with timely and efficient discharge planning for hospitalized patients.
• Initiates and follows up on referrals to skilled nursing facilities, assisted living communities, residential settings, home health agencies, outpatient providers, and other appropriate community resources.
• Contacts facilities and community providers to determine placement availability and obtain information necessary to coordinate patient discharge.
• Assists with gathering and sending required clinical documentation for referrals and placement.
• Tracks pending referrals and follows up with facilities regarding acceptance, denial, or additional information needed.
• Communicates discharge planning updates to the Social Services Director and interdisciplinary treatment team.
• Assists with communication between patients, families/responsible parties, nursing staff, providers, and community agencies regarding discharge needs.
• Helps coordinate transportation, follow-up appointments, community resources, and other discharge-related services as directed.
• Conducts post-discharge follow-up calls with patients, families, facilities, or other responsible parties to confirm successful transition and identify concerns requiring additional follow-up.
• Documents post-discharge contacts and communicates identified concerns to the appropriate Hospital team member.
• Maintains an organized system for tracking anticipated discharges, referrals, placement status, barriers to discharge, and follow-up needs.
• Assists with obtaining information regarding patient psychosocial needs and available community resources.
• Participates in treatment team or interdisciplinary meetings as requested.
• Completes documentation and progress notes within the scope of the position and according to Hospital policy.
• Maintains patient confidentiality and complies with HIPAA, Hospital policies, and applicable state and federal requirements.
• Maintains professional communication with patients, families, referral sources, facilities, and community partners.
• Other duties as assigned

Corterra of Wichita is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.