Home Health Care Transition Coordinator

Compassus; Neenah (WI); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Wellness programs

Job summary

Compassus is seeking a Home Health Care Transition Coordinator (RN preferred; LPN considered) to guide patients from hospital to home-based services, including hospice and infusion. You will collaborate with physicians, case managers, and families to plan post-acute care, ensuring timely, patient-centered transitions across care settings.

Qualifications include BSN and active RN license; 2–3 years nursing experience with home health exposure is highly valued.

Qualifications

• Bachelor’s degree preferred.
• Two to three years of nursing experience as an RN highly preferred.
• LPN may be considered.
• Hospital and/or long-term care clinical experience highly preferred.
• Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, and end-of-life practices.

Responsibilities

• Meets regularly with physicians to discuss patients and ensures continuity of care.
• Acts as hospital case manager and performs high-risk patient reviews.
• Educates on hospice, home infusion, and home health benefits to families and referrals.
• Develops relationships with clinicians and problem-solves through case reviews.
• Coordinates care by obtaining orders, records, and documentation promptly.
• Identifies patient post-acute care needs and aligns with primary care team.

Skills

Nursing coordination

Hospital-to-home transition

Excellent communication

Patient-centered care

Education

Bachelor's degree in Nursing (BSN)

RN license

Job description

Company: Ascension at Home together with Compassus Position Summary Registered Nurse preferred for this role. LPN can be considered. The Home Health Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Care Transition Coordinator serves as a trusted resource for the physician and hospital case managers and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Health Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Meets regularly with physicians in the hospital to discuss specific patients: gives guidance and provides an understanding of post-acute service support; ensures continuity of care as a priority.
• Acts as hospital case managers (rounding or interactions in step with the hospital): high-risk patient reviews.
• Supports transition to home health, home infusion, and hospice services by conducting in-person bedside transitions; where services are offered.
• Educates on hospice, home infusion, and home health benefits to patient families and referral sources.
• Develops genuine collegial relationships with other Ascension professionals and identifies times to meet regularly with clinicians to problem solve and review cases.
• Understands how to interact with difficult patients/families.
• Identifies steps to having a successful family meeting.
• Develops communication skills to support patients/families with difficult discussions or differing points of view.
• Maintains a current list of admission coordinators for each healthcare service line.
• Aligns recommendations between patient/family and Primary care team: Identifies patient preferences/needs.
• Identifies patient’s post-acute care needs.
• Confirms the level of care most appropriate for the patient - right care, right time.
• Educates patient on Homebound criteria and verifies patient meets this requirement.
• Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing a transition to the home plan.
• Sets patient-centered goals and facilitates transitions: Understands how to identify patient/family-specific treatment goals.
• Arranges for home admission – communication with the Home Health and Home Infusion team(s).
• Coordinates patient care by obtaining H&P, physician orders, hospital records, and face-to-face documentation promptly.
• Verifies patient demographic information is correct.
• Coordinates organization of transfer orders; educates patients on home care orders and home care services.
• Identifies primary care physician to follow the plan of care.
• Conducts follow-up on re-hospitalized home health patients.
• Participates in home health re-hospitalization mitigation strategies – be a member of the strategy team.
• Develops ability to understand and digest claims data, and use of predictive analytics.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts.
• Consistently works to improve personal knowledge and sales skills to become of greater value to our most important customers and the company.
• Meets or exceeds assigned quotas, thereby maintaining and constantly improving the HH's competitive position.
• Performs other duties as assigned.

Education and/or Experience

• Bachelor’s degree preferred.
• Two (2) to three (3) years of nursing experience as an RN highly preferred.
• LPN may be considered.
• Hospital and/or long‑term care clinical experience highly preferred.
• Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, introduction to end‑of‑life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, and estimating and communicating prognosis/disease trajectory preferred.

Skills

Mathematical Skills:

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to compute rate, ratio, and percentage.

Language Skills:

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties.
• Strong written and verbal communications.

Other Skills and Abilities:

• Ability to understand, read, write, and speak English.
• Articulates and embraces hospice philosophy.

Certifications, Licenses, and Registrations

• Active and unencumbered Registered Nurse license in the state(s) of employment.
• A Graduate of an accredited Licensed Practical/Vocational Nurse program may be considered.

Physical Demands and Work Environment

The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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Build a Rewarding Career with Compassus At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others. Your Career Journey Matters We’re dedicated to helping you grow and succeed. Whether you’re pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.

The Compassus Advantage

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

Ready to Join? At Compassus, your career is more than a job—it’s an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive. Compassus provides a continuum of integrated home-based services including home health, home infusion, palliative and hospice care. Thousands of teammates and hundreds of access points nationwide provide high-quality care and manage patients’ advanced illnesses in partnership with health systems and long-term care partners. The Compassus Care for who I am culture reflects its unique care delivery model, which focuses on each person as an individual as well as a patient, to improve their quality of life in a meaningful way. Learn more at compassus.com or follow @Compassus on Facebook, LinkedIn, Instagram or Twitter.