Post Acute Care Coordinator

Evolving Solution Services; Atlanta (GA); Hybrid; USD 60,000 - 80,000; Full time

Job summary

Evolving Solution Services in Atlanta, GA seeks a Post Acute Transition Coordinator to bridge hospitals, patients, and post-acute providers for smooth transitions from hospital to home or SNF, rehab, or home-based services.

The role requires a bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field, 2+ years in care coordination or discharge planning, and AMR/EHR proficiency. RN/CCM credentials are a plus.

Qualifications

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field
• 2+ years of experience in care coordination, case management, or discharge planning within a healthcare environment
• Proficiency with EHR systems and care management software
• Registered Nurse (RN) license or CCM credential preferred
• Experience with Medicare/Medicaid/insurance authorization processes

Responsibilities

• Coordinate seamless care transitions from hospital discharge to skilled nursing, rehab, or home-based services
• Develop individualized care plans by collaborating with physicians, nurses, social workers, and families
• Communicate across settings to ensure continuity, timely documentation and patient experience
• Monitor progress post-discharge and address barriers to care or readmission risks
• Promote best practices and regulatory compliance
• Advocate for patients and families navigating complex healthcare systems

Skills

Care coordination

Discharge planning

Communication

Organizational skills

Education

Bachelor’s degree in Nursing, Social Work, Healthcare Administration

RN license

CCM credential

Tools

MS Project

Smartsheet

Asana

MS Office

Job description

Shape the Future of Post-Acute Care Coordination

Are you passionate about improving patient outcomes and ensuring smooth care transitions? Join our Network Development Team as a Post Acute Transition Coordinator — a vital role that bridges hospitals, patients, and post-acute providers to deliver seamless, compassionate care during one of the most critical stages of recovery.

As a trusted care connector, you’ll coordinate the journey from hospital to home or post-acute care facilities, ensuring each patient receives the support, resources, and follow-up they need to thrive. Your work will help reduce readmissions, strengthen partnerships, and elevate the quality of care across our network.

What You’ll Do

Coordinate seamless care transitions from hospital discharge to skilled nursing, rehab, or home-based services.

Develop individualized care plans by collaborating with physicians, nurses, social workers, and families.

Communicate across settings to ensure continuity, timely documentation, and exceptional patient experiences.

Monitor progress post-discharge and proactively address barriers to care or readmission risks.

Promote best practices and compliance with all care coordination and regulatory standards.

Serve as a trusted advocate for patients and families navigating complex healthcare systems.

What You Bring

Minimum Qualifications

Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field

2+ years of experience in care coordination, case management, or discharge planning within a healthcare environment

Strong understanding of post-acute care services and patient discharge processes

Excellent communication, collaboration, and organizational skills

Proficiency with EHR systems and care management software

Preferred Qualifications

Registered Nurse (RN) license or Certified Case Manager (CCM) credential

Experience supporting diverse or complex patient populations

Familiarity with Medicare, Medicaid, and insurance authorization processes

Training in motivational interviewing or patient advocacy

Advanced certifications in care coordination or transitions of care

Your Strengths

Skilled at juggling multiple patient cases while keeping care quality front and center

Analytical thinker who can identify risks and implement effective care plans

Relationship-builder who foster trust and cooperation across multidisciplinary teams

Confident navigating healthcare regulations and insurance systems

Tech-savvy professional with proficiency in MS Office and healthcare data tools (MS Project, Smartsheet, Asana, etc.)

Why You’ll Love Working Here

Make a measurable impact on patients’ recovery journeys and long‑term well‑being

Collaborate with mission‑driven professionals who share your passion for high‑quality care

Grow your career through exposure to diverse healthcare systems and innovative care coordination practices

Enjoy flexibility across regional roles (Southwest, Central, Northwest) with a supportive leadership team that values balance, integrity, and collaboration

Travel & Field Engagement Requirements

This role includes a significant in‑person component. Approximately 50% of the position involves local travel to Skilled Nursing Facilities and other post‑acute care settings to build relationships, support network growth, and establish ongoing meeting cadence with partner facilities.

Candidates must be comfortable with frequent travel, have reliable personal transportation, and be willing to conduct regular on‑site visits. Travel expenses will be reimbursed.

Physical Demands:
This position requires periods of sitting, standing, and working at a computer. Occasional lifting (up to 10 lbs) may be needed.

Equal Opportunity Employer
We celebrate diversity and are committed to creating an inclusive environment for all employees.

Ready to make a difference in how patients experience post-acute care ?