Care Transitions Navigator

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

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