Care Transition Coordinator

Corterra-of-Wichita,-LLC; Wichita (KS); On-site; USD 55,000 - 75,000; Full time

Job summary

Corterra of Wichita in Wichita, KS, seeks a compassionate Care Transition Coordinator to coordinate patient intake and discharge planning. You will work with an interdisciplinary team to ensure safe, timely transitions and smooth placement with facilities, home health, and community resources.

You will support referrals, communicate with families, arrange transportation, document progress, and maintain HIPAA compliance while building strong community partnerships.

Qualifications

• BSW or MSW preferred but not required.
• Current students in Social Work, Psychology, Human Services, Healthcare, or related fields encouraged to apply.
• Acute Care Discharge Planner/SSD or experience in long-term care, behavioral health, case management, discharge planning or healthcare encouraged to apply.
• Previous experience 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

• Assist Director of Admissions with intake of new patients.
• Assist Social Services Director with discharge planning for hospitalized patients.
• Initiate and follow up on referrals to SNFs, assisted living, residential settings, home health agencies, outpatient providers, and community resources.
• Coordinate placement information with facilities and providers.
• Gather and send required clinical documentation for referrals and placement.
• Track pending referrals and follow up on acceptance, denial, or information needs.
• Communicate discharge planning updates to the Social Services Director and team.
• Coordinate communication among patients, families, nursing staff, providers, and community agencies.
• Facilitate transportation, follow-up appointments, and other discharge-related services.
• Conduct post-discharge follow-up calls to confirm successful transitions and identify concerns.
• Document post-discharge contacts and escalate concerns to appropriate hospital staff.
• Maintain an organized tracking system for anticipated discharges, referrals, placement status, and barriers.
• Obtain information on psychosocial needs and available community resources.
• Participate in treatment team meetings as requested.
• Complete documentation and progress notes per policy and scope.
• Maintain patient confidentiality and HIPAA compliance.
• Maintain professional communication with patients, families, referral sources, facilities, and partners.
• Other duties as assigned.

Skills

Discharge planning

Case management

Communication with families

Interdisciplinary teamwork

Post-discharge follow-up

Education

BSW or MSW preferred

Current students in related fields encouraged

Experience in discharge planning/long-term care/behavioral health encouraged

Experience with older adults in healthcare settings preferred

BLS & First Aid certification required

Hospital competencies and training completion

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.