Transition of Care Coordinator

COMMUNITY HEALTH CARE INC; West Fulton (OH); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

401(k) and Roth 401(k)

401(k) employer match

Dental insurance

Term Life Insurance

Vision insurance

Wellness benefits

Paid time off

Personal days

Short term disability

Long Term disability

Paid holidays

Employee assistance program

Travel assistance program

Job summary

Community Health Care Canal Fulton seeks an in-office Transition of Care Coordinator (RN or LPN) to coordinate patient transitions from inpatient to home, improving outcomes. This fast-paced, team-oriented practice values compassionate, patient-centered care.

You will work across hospital systems and skilled nursing facilities, reconcile medications, arrange home care, and ensure timely follow-up. In-office role offering supportive colleagues and opportunities to impact community health.

Qualifications

• RN or LPN license required and knowledge of area hospital systems.
• Experience with medication reconciliation and cross-system coordination.
• Ability to work across multiple Electronic Health Record platforms.

Responsibilities

• Coordinate patient transitions from inpatient to home or home health services.
• Conduct post-discharge coordination and ensure timely follow-up.
• Reconcile medications and update patient charts across systems.
• Collaborate with hospital nurses and care management staff.
• Act as patient advocate and support care planning in office.
• Perform organizational tasks to maintain smooth workflow.

Skills

Clinical decision making

Critical thinking

Teaching others

Verbal communication

Written communication

Teamwork

Education

RN or LPN license

Tools

EHR platforms

Job description

Description

JOIN OUR TEAM!

Community Health Care is a privately owned corporation that has a 38-year history of providing our patients with the highest quality of innovative, comprehensive health care, and health care services, that are compassionate, support, personal, convenient, and cost effective. We are actively engaged in the communities that we serve and strive to recruit the finest staff possible, giving maximum support and encouragement to foster growth and pride in the organization.

Community Health Care Canal Fulton is looking for an in-office Transition of Care Coordinator (RN) with a passion for helping others by coordinating patient transitions of care from an inpatient setting to improve patient care and outcomes. Our office is energetic, team oriented, and dedicated to providing excellent patient-centered care. If you would like to work for an established medical practice that values both patients and employees,

Responsibilities:

Patient care

• Conduct post-discharge patient interview via phone
• Assess and identify patient needs post-discharge
• Reconcile medication list post-discharge
• Coordinate patient care such as home care or medical equipment
• Work collaboratively with hospital-based transition of care nurses and staff
• Act as patient advocate
• Organizational tasks
• Identify patients who have had a transition of care
• Contact patients within 48 hours of inpatient discharge or within 7 days of Emergency Room visit
• Follow patient course of stay while in Skilled Nursing Facility until discharge to home
• Retrieve patient records from multiple hospital systems, review records, update patient chart
• Concurrent documentation in telephone encounters in patient chart
• Refer patients to long-term care management when appropriate

Requirements:

• Education: Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• Specialized knowledge: comprehensive knowledge of area hospital systems and skilled nursing facilities; medication reconciliation; ability to work in multiple Electronic Health Record platforms
• Skills: clinical decision making; critical thinking for individualized patient care; ability to teach others, including patients, peers, and staff
• Abilities: self-motivated; strong verbal and written communication skills; flexible; teamwork within individual offices and care management team
• In office setting

Benefits:

• Medical insurance
• 401(k) and Roth 401(k)
• 401(k) employer match
• Dental insurance
• Term Life Insurance
• Vision insurance
• Wellness benefits
• Paid time off
• Personal days
• Short term disability
• Long Term disability
• Paid holidays
• Employee assistance program
• Travel assistance program