Home Care Transition Navigator

Trinity Health; Chelsea (ME); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Paid holidays PTO

Tuition reimbursement

Vendor discounts

Day1 benefits

Daily-pay

Fast interviews

Job summary

Trinity Health At Home seeks a compassionate Home Care Coordinator to support patients transitioning from acute care to home-based services. You will facilitate referrals, educate clinical teams, and collaborate across the healthcare continuum to ensure high-quality, patient-centered care.

You will engage with case managers, discharge planners, and care teams to coordinate seamless discharges, assess home care needs, and document in accordance with agency policies.

Qualifications

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

Written communication

Customer service

Acute care experience

Education

Bachelor’s degree or equivalent

Clinical education and state license preferred

Job description

Trinity Health At Home seeks a compassionate Home Care Coordinator to support patients transitioning from acute care to home-based services. You will facilitate referrals, educate clinical teams, and collaborate across the healthcare continuum to ensure high-quality, patient-centered care.

You will engage with case managers, discharge planners, and care teams to coordinate seamless discharges, assess home care needs, and document in accordance with agency policies.