Home Care Transition Coordinator | Discharge & Continuity

Trinity Health At Home; Chelsea (MI); On-site; USD 60,000 - 72,000; Full time

Benefits offered by this job

Paid holidays & PTO

Tuition reimbursement

Vendor discounts

Health benefits (Day 1)

Job summary

Trinity Health At Home is seeking a compassionate, organized Home Care Coordinator to support patients transitioning from acute care to home-based services. You will facilitate timely referrals to home care and hospice, educate clinical teams on available services, and collaborate across the healthcare continuum to ensure patients receive the highest standard of care.

This role coordinates care across hospital units and community providers, maintains documentation, and contributes to quality

Qualifications

• Bachelor’s degree or equivalent experience required.
• Clinical education and current state clinical license preferred.
• Minimum 2 years’ experience in acute care, customer service, sales/marketing, or a related field.
• Strong verbal and written communication skills.

Responsibilities

• Serve as the primary liaison between hospital care teams, patients, and Trinity Health At Home to coordinate safe and seamless discharges.
• Maintain daily communication with case managers, discharge planners, and acute care units to follow up on referrals promptly.
• Conduct initial assessments of home care needs, review hospital medical records, and prepare documentation according to agency policies.
• Coordinate services based on admission criteria, patient preferences, and clinical needs, securing physician orders in accordance with regulatory requirements.
• Provide education to patients, families, physicians, and healthcare staff regarding home care, hospice, and community resources.
• Facilitate communication across physicians, hospital units, intake teams, and other care providers to support continuity of care.
• Participate in quality improvement activities, business development efforts, and new program implementation.
• Maintain confidentiality, ethical practice, accurate documentation, and adherence to compliance requirements.

Skills

Verbal and written communication

Education

Bachelor’s degree or equivalent experience

Job description

Trinity Health At Home is seeking a compassionate, organized Home Care Coordinator to support patients transitioning from acute care to home-based services. You will facilitate timely referrals to home care and hospice, educate clinical teams on available services, and collaborate across the healthcare continuum to ensure patients receive the highest standard of care.

This role coordinates care across hospital units and community providers, maintains documentation, and contributes to quality