Transitional Care Coordinator

Svdpnky; Amarillo (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

ExcelaCare Home Health and Hospice is seeking a Transitional Care Coordinator to manage patient transitions from hospital to home health care. You will coordinate with hospital staff, home health teams, patients, and families to ensure continuity of care and effective communication.

Responsibilities include conducting assessments, developing care plans, coordinating discharge, and educating families about care processes.

Qualifications

• Bachelor's degree in related field (Healthcare Administration, Business, or Marketing preferred).
• 2 years nursing or social work experience.
• 1 year of home care, intake or case management experience.
• Driver’s license and auto liability insurance; no OIG exclusion.
• RN license in the practicing state; additional certification in case management or transitional care coordination are a plus.

Responsibilities

• Conduct comprehensive assessments of patients transitioning from hospital to home health care.
• Develop and implement individualized care plans with providers, patients, and families.
• Evaluate home environment for suitability of care needs.
• Serve as liaison between hospital staff, home health teams, and patients/families.
• Ensure timely transfer of medical information and care plans.
• Coordinate discharge process and arrange equipment, medications, and supplies.
• Schedule follow-up appointments and coordinate transportation.
• Monitor patient progress and address transition issues.
• Educate patients and families about home health care process and self-care.
• Maintain confidential patient records in line with regulations.

Skills

Organizational skills

Supervisory ability

Clinical assessment

Teamwork

Communication

Time management

Interpersonal communication

Math skills

Education

Bachelor's degree in Healthcare Administration, Business, or Marketing preferred

Job description

Transitional Care Coordinator - Home Health & Hospice

About Us

At ExcelaCare Home Health and Hospice, we believe Home Health & Hospice care is more than a service—it’s a calling. Every day, our team brings comfort, dignity, and peace of mind to patients and families facing life’s most delicate moments. With compassion at our core, we create a workplace where kindness leads, voices are heard, and every role carries purpose. If you’re looking to make a difference in the lives of others while being part of a team that feels like family, we’d love to welcome you.

Job Summary

The Transitional Care Coordinator is responsible for managing the transition of patients from hospital care to home health care services. This role involves coordinating with hospital staff, home health care teams, patients, and their families to ensure continuity of care, compliance with care plans, and effective communication across all parties.

Essential Functions

• Conduct comprehensive assessments of patients transitioning from hospital to home health care.
• Develop and implement individualized care plans in collaboration with healthcare providers, patients, and their families.
• Evaluate the patient’s home environment to ensure it is suitable for their care needs.
• Serve as the primary liaison between hospital staff, home health care teams, patients, and their families.
• Ensure timely and accurate transfer of medical information and care plans.
• Facilitate communication between all parties involved in the patient’s care
• Coordinate the discharge process from the hospital, ensuring all necessary medical equipment, medications, and supplies are arranged.
• Schedule follow-up appointments and coordinate transportation if needed.
• Monitor patients’ progress and address any issues that arise during the transition period.
• Educate patients and their families about the home health care process, care plans, and self-care techniques.
• Provide ongoing support and resources to patients and families to help them manage their health conditions at home.
• Maintain accurate and up-to-date patient records in accordance with healthcare regulations and organizational policies.
• Ensure compliance with all relevant health care standards and protocols.
• Monitor and report on patient outcomes and the effectiveness of transitional care plans.
• Work closely with multidisciplinary teams including physicians, nurses, social workers, and therapists to coordinate comprehensive care.
• Participate in regular team meetings and case conferences to discuss patient care plans and progress.

Additional Responsibilities

• Performs other duties as assigned or requested.
• Conforms to all applicable Agency policies and procedures.
• Participates actively in continuing education and in-services.
• Maintains confidentiality of patient information and business trade practices
• Assumes accountability for reporting incidents and complaints according to Agency policy.

Knowledge / Skills / Abilities

• Organizational skills
• Ability to supervise in accordance with Agency’s policies and applicable laws.
• Strong clinical assessment and care planning skills
• Ability to work independently and as part of a team
• Ability to respond to common inquiries or complaints, regulatory agencies, or members of the business community.
• Time management
• Advanced written and verbal interpersonal communication
• Basic math skills related to patient care.

Age-Related Competencies

Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.

Information Management

Treats all information and data within the scope of the position with appropriate confidentiality and security.

• Cooperates fully in all risk management activities and investigations.
• Keeps abreast of changes in health care law.
• Maintains Agency/program compliance with local, state, and federal laws as well as state accreditation standards.

Minimum Position Qualifications

• Bachelor's degree in a related field (Healthcare Administration, Business, or Marketing preferred).
• 2 years nursing or social work experience
• 1 year of home care, intake or case management experience
• Driver’s license and proof of current auto liability insurance; no listing in the OIG Excluded Provider listing
• Registered Nurse license in the state practicing. Additional certification in case management or transitional care coordination are a plus

Environmental Conditions

Works under a variety of conditions in facilities and offices; ability to work flexible schedule, ability to travel locally; some exposure to unpleasant weather. Moderate noise level; tasks may involve exposure to bloodborne pathogens; moderate stress and emotional demands.

Physical Requirements

Sitting is required. Requires ability to always handle stressful situations in a calm and courteous manner. Requires working under some stressful conditions to meet deadlines and agency needs. Ability to travel.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities.