Transitional Care Coordinator

Doctor's Choice Home Care; La Marque (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

Doctor's Choice Home Care is seeking a Transitional Care Coordinator to facilitate smooth discharges from facilities to post-acute care. You will assess health literacy, coordinate with referral sources, obtain documentation, and include patients and families in care planning.

You will partner with the Agency to ensure patient-centric plans and optimal outcomes, using clinical, sales, and communication skills to support growth and high-quality care.

Qualifications

• High School Diploma or GED required; degree preferred in nursing or allied health.
• Current RN or LVN licensure; CPR certification required.
• Excellent written/verbal communication and listening skills.
• Ability to manage conflict, stress, and multiple tasks professionally.
• Experience with state CMS and accreditation processes is a plus.

Responsibilities

• Coordinate patient transitions from facility to home care or post-acute settings.
• Assess health literacy and caregiver needs; involve patient in care planning.
• Communicate with referral sources and discharge providers to obtain required documentation.
• Collaborate with internal and external teams to ensure patient-centric plans and outcomes.
• Travel between facilities and home care agency as needed (75-100%).

Skills

Registered Nurse

LVN

CPR Certified

Communication skills

Time management

Relationship building

Problem solving

Education

High School Diploma or GED

Associate's degree in nursing

Bachelor's degree in nursing

Allied health degree

Tools

EMR software

Microsoft Word

Excel

Outlook

Job description

Summary of Essential Functions for the Position:Committed to Caring, the Transitional Care Coordinator (TCC) is a clinical team member of the sales team and is responsible for facilitating a seamless transition for patients discharging from a facility setting to one that facilitates post-acute needs, by communicating and collaborating with both internal and external teams to a support patient-centric care. The TCC will assess patients to determine their level of health literacy, assess for patient and caregiver needs, coordinate between the referral sources and discharge provider to assure needed documentation is obtained, and ensure patients and families are included in care planning. Once the transition is accomplished, the TCC will work and coordinate with the Agency to ensure that there are patient centric plans in place to ensure optimal patient outcomes. The TCC must possess the ability to communicate and collaborate with other individuals in many different settings, utilizing their clinical, sales, marketing, negotiation, problem solving, and analytical skills that lead to company market development initiatives and growth while focusing on serving more patients with excellent outcomes.Qualifications / Licensure / Certification / Knowledge / Skills / Abilities:A minimum of one (1) year experience in a health care organization, home care and/or hospice preferred.LVN, RN required.CPR certified with American Heart Association or American Red Cross if a clinical.Possess excellent written, verbal and listening communication skillsAbility 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 practicesPossess sound organizational skills to include time management and problem solvingExperience with State, CMS and/or accreditation survey processMust demonstrate good customer relations skills and a commitment to providing quality serviceFamiliarity with healthcare laws, regulations, multiple accreditation standards and elements of performanceProficient with a computer and Microsoft Word, Excel and Outlook software. Working knowledge of EMR database.Ability to work with culturally diverse clients and address low literacy issue in care provisionAcceptance and ability to demonstrate and support the core values and goals of AgencyValid driver’s license, automobile liability insurance and reliable transportation requiredTravel between facilities, hospitals and home care agency is required. Approximately 75%-100% travel.Educational Requirements:High School Diploma or GED. Associate’s or bachelor’s degree in nursing or allied health preferred.Working Conditions & Physical Requirements:Work environment is relatively quiet and can be stressful due to deadlines, multiple tasks and general compliance of law, rules, and regulations. The position requires visual acuity and dexterity, sitting, standing, some pushing, pulling, and lifting up to 25 pounds. Auto related accidents possible