Post-Acute Care Transition Specialist

Doctor's Choice Home Care & Hospice Texas; Arlington (TX); On-site; USD 60,000 - 86,000; Full time

Job summary

Doctor's Choice Home Care & Hospice Texas seeks a Transitional Care Coordinator to streamline patient transitions from facility discharge to post-acute care. You will coordinate with internal and external teams to support patient-centric care planning and ensure essential documentation is obtained.

The role requires assessing health literacy, caregiver needs, and collaboration across referrals and discharge providers, with travel 75–100% as needed to support seamless transitions and optimal

Qualifications

• Minimum of one year experience in a health care organization; home care and/or hospice preferred.
• LVN or RN required.
• CPR certification with American Heart Association or American Red Cross if a clinical.
• Excellent written, verbal and listening communication skills.
• Ability to manage conflict, stress and multiple simultaneous work demands in an effective, professional manner.
• Ability to work independently, while collaborating with other team members, build relationships and be results driven.
• Strong understanding of customer and market dynamics, as well as transitional care best practices
• Possess sound organizational skills to include time management and problem solving
• Familiarity with healthcare laws, regulations, multiple accreditation standards and elements of performance
• Proficient with a computer and Microsoft Word, Excel and Outlook software. Working knowledge of EMR database.

Responsibilities

• Facilitate seamless transitions for patients discharging from facility settings to post-acute care.
• Communicate and collaborate with internal and external teams to support patient-centric care planning.
• Assess health literacy and caregiver needs; coordinate documentation with referral sources and discharge providers.
• Include patients and families in care planning and ensure documentation is obtained.
• Coordinate with the Agency to implement patient-centric plans and optimize outcomes.
• Travel between facilities, hospitals and home care agency as needed.

Skills

Communication

Conflict resolution

Time management

Organizational skills

Problem solving

Team collaboration

Customer relations

Transitional care knowledge

Market dynamics

MS Word/Excel/Outlook

Education

High school diploma or GED

Associate's or Bachelor's in nursing or allied health preferred

Tools

MS Word

Excel

Outlook

EMR database

Job description

Doctor's Choice Home Care & Hospice Texas seeks a Transitional Care Coordinator to streamline patient transitions from facility discharge to post-acute care. You will coordinate with internal and external teams to support patient-centric care planning and ensure essential documentation is obtained.

The role requires assessing health literacy, caregiver needs, and collaboration across referrals and discharge providers, with travel 75–100% as needed to support seamless transitions and optimal