Post-Discharge Transitional Care Coordinator (Home Health)

Segue Health Management Corp; Memphis (TN); On-site; USD 45,000 - 55,000; Full time

Benefits offered by this job

Competitive Benefits Provided

Job summary

Segue Health, a faith-based medical practice in Memphis, is seeking a compassionate Care Coordinator to support post-discharge transitional care management for patients in Baptist East, Memphis and surrounding areas.

The role requires clinical knowledge, strong organizational and communication skills, and the ability to collaborate with referring facilities to identify eligible patients and coordinate care at home.

Qualifications

• Experience in the medical field is required.
• Proficiency with Microsoft Excel and ability to learn EMR/EHR software.
• Reliable transportation to local hospitals required.
• Candidates with social work, nursing, or home health background are preferred.
• Excellent organizational and communication skills are essential and vaccinations may be required.

Responsibilities

• Identify patients eligible for transitional care management (TCM) services with facilities.
• Visit referrals in facilities to explain the TCM program and assess post-discharge needs.
• Log referrals and discharges daily for tracking and reporting.
• Create charts in EMR and upload face sheet, H&P, and discharge summary documents.
• Make post-discharge calls to patients within 24 hours of discharge.
• Schedule patients for in-home visits preferably before discharge.

Skills

Medical field exp

Excel

EMR/EHR

Transportation

Attention to detail

Communication

Tools

EMR/EHR software

Job description

Segue Health, a faith-based medical practice in Memphis, is seeking a compassionate Care Coordinator to support post-discharge transitional care management for patients in Baptist East, Memphis and surrounding areas.

The role requires clinical knowledge, strong organizational and communication skills, and the ability to collaborate with referring facilities to identify eligible patients and coordinate care at home.