Care Transition Navigator for Patient Discharges

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

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.