Care Transitions Navigator: Seamless Discharges

Independent Living Systems; Lehigh Acres (FL); On-site; USD 45,000 - 65,000; Full time

Job summary

Independent Living Systems in Lehigh Acres, FL seeks a Care Transitions Coordinator to manage patient transitions across care settings, ensuring safe, timely discharges and coordination with hospitals, nursing facilities and community resources.

Position emphasizes collaboration with care managers, families and providers to optimize outcomes and reduce avoidable readmissions; requires 2+ years of relevant experience and a relevant degree or Florida-licensed RN/LPN along with EHR proficiency.

Qualifications

• Minimum of two years of relevant experience.
• Strong knowledge of healthcare systems, discharge planning and community resources.
• Excellent communication and interpersonal skills to collaborate with diverse stakeholders.
• Proficiency in electronic health records (EHR) and basic computer applications.

Responsibilities

• Demonstrate commitment to Our Mission and ILS Experience Standards of Excellence.
• Develop, implement and coordinate individualized transition plans with care management teams and providers.
• Coordinate communication between hospitals, nursing facilities, and community resources for safe transitions.
• Monitor member progress after discharge to reduce readmissions and adverse outcomes.
• Arrange post-discharge services, equipment, medications, transportation and follow-up appointments.
• Educate members and families on discharge instructions, follow-up care and self-management.
• Identify barriers to successful transitions and resolve care gaps.
• Maintain timely documentation of transition activities and outcomes.

Skills

Healthcare systems knowledge

Discharge planning

Communication skills

Interpersonal skills

EHR proficiency

Education

Bachelor's degree in social work

RN license (Florida)

LPN license (Florida)

Tools

EHR systems

Job description

Independent Living Systems in Lehigh Acres, FL seeks a Care Transitions Coordinator to manage patient transitions across care settings, ensuring safe, timely discharges and coordination with hospitals, nursing facilities and community resources.

Position emphasizes collaboration with care managers, families and providers to optimize outcomes and reduce avoidable readmissions; requires 2+ years of relevant experience and a relevant degree or Florida-licensed RN/LPN along with EHR proficiency.