Care Transitions Coordinator

Independent Living Systems, llc; Lehigh Acres (FL); On-site; USD 52,000 - 68,000; Full time

Job summary

Independent Living Systems, LLC in Lehigh Acres, FL is seeking a Care Transitions Coordinator to manage patient transitions from nursing facilities to community settings. The role focuses on safe, timely, and coordinated moves while preventing avoidable readmissions.

You will develop, implement and monitor individualized transition plans, collaborate with care managers, hospitals, facilities, families and community resources, and ensure adherence to care plans through effective communication and

Qualifications

• Bachelor’s degree in social work, sociology, psychology, gerontology, or related social services field.
• Bachelor's degree in a field other than social science.
• Master’s degree in social work, public health or related field preferred.
• CCM certification or equivalent preferred.

Responsibilities

• Develop, implement and coordinate individualized transition plans with care management teams, members, families and providers.
• Coordinate communication between hospitals, nursing facilities, SNFs, ALFs, PCPs, specialists and community resources for safe transitions.
• Monitor member progress post-discharge and address gaps or concerns to reduce readmissions and adverse outcomes.
• Arrange post-discharge services, equipment, medications, transportation, and follow-up appointments.

Skills

Healthcare systems knowledge

Discharge planning

Communication skills

EHR proficiency

Team collaboration

Education

Bachelor’s degree in social work, sociology, psychology, gerontology, or related social services field

Bachelor's degree in a field other than social science

Master’s degree in social work, public health or related field

CCM certification

Tools

EHR software

Basic computer applications

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Care Transitions Coordinator

Full Time Clerical Lehigh Acres, FL, US

We are seeking a Care Transitions Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Care Transitions Coordinator plays an essential role in managing and coordinating member transitions between different care settings. This role is primarily focused on transitions from nursing facilities to community-based settings and, when appropriate, preventing avoidable transitions from the community to nursing facility placement. The Care Transitions Coordinator is responsible for developing, implementing and coordinating individualized transition plans; collaborating with multidisciplinary teams; and addressing barriers that may impact successful and safe transitions. Working closely with Care Managers, members, families, providers and community resources, the Care Transitions Coordinator helps optimize health outcomes, promote continuity of care, and reduce avoidable readmissions or institutional placements. By managing the logistical and care coordination components of transitions, the Care Transitions Coordinator supports member safety, satisfaction, and adherence to care plans.

Minimum Qualifications:

• With the following qualifications, have a minimum of two (2) years of relevant experience:
• Bachelor’s degree in social work, sociology, psychology, gerontology, or related social services field.
• Bachelor's degree in a field other than social science.
• Registered Nurse (RN) licensed to practice in the state of Florida.
• Licensed Practical Nurse (LPN) with a minimum of four (4) years licensed to practice in the state of Florida.
• Relevant professional human service experience may substitute for the educational requirement on a year-for-year basis.
• Strong knowledge of healthcare systems, discharge planning, and community resources.
• Excellent communication and interpersonal skills to effectively collaborate with diverse stakeholders.
• Proficiency in electronic health records (EHR) and basic computer applications.

Preferred Qualifications:

• Master’s degree in social work, public health or related field.
• Certification in Case Management (CCM) or equivalent.
• Experience working with diverse populations in community-based or facility (ALF or SNF) settings.
• Familiarity with trauma-informed care or behavioral health interventions and supports.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Develop, implement and coordinate individualized transition plans in collaboration with care management teams, members, families and providers.
• Coordinate communication between hospitals, nursing facilities, assisted living facilities, primary care providers, specialists, and community resources to ensure safe, timely, and seamless transitions between care settings.
• Collaborate with the care managers to monitor member progress following discharge or transition promptly addressing complications, service gaps, or concerns to reduce avoidable readmissions and adverse outcomes.
• Arrange and confirm post-discharge services, equipment, medications, transportation, and follow-up appointments necessary to support successful transitions.
• Educate members and their families regarding discharge instructions, follow-up care, available resources, and self-management strategies to promote independence and adherence to care plans.
• Identify and resolve barriers to successful transitions, including access to services, housing, caregiver support, and provider coordination issues.
• Maintain accurate, complete and timely documentation of transition activities, outreach efforts, and outcomes in accordance with regulatory, contractual, and organizational requirements.