Transitional Care Coordinator

Plan A Health; Oak Lawn (IL); On-site; USD 52,000 - 76,000; Full time

Job summary

Health, Inc in Oak Lawn, IL is seeking a Transitional Care Navigator to support patients and families during care transitions from hospital stays to home or community services. You will coordinate discharge planning, arrange follow-up appointments, and connect clients with personal care, home health, or hospice services to promote safe, timely transitions and reduce readmissions.

This role requires strong communication, the ability to coordinate services, and a compassionate, patient-centered

Qualifications

• Excellent communication with patients and families.
• Capable of coordinating services and managing transition details.
• Collaborates with interdisciplinary teams to align care plans.
• Advocates for safe, timely and respectful care.

Responsibilities

• Coordinate and oversee discharge planning and transition of care.
• Schedule and confirm follow-up appointments and care-related services.
• Connect clients with relevant care programs and community resources.
• Collaborate with interdisciplinary teams to align care plans and needs.
• Educate patients and families on care plans, available resources, and next steps.
• Advocate for dignity, respect, and independence throughout the transition process.

Skills

Communication skills

Patient education

Care coordination

Interdisciplinary collaboration

Job description

Transitional Care Navigator supports patients and families during care transitions from hospital or facility settings to home or community-based services. The role coordinates discharge plans, arranges follow-up appointments, and connects clients with appropriate personal care, home health, or hospice services to promote safe, timely transitions and help reduce readmissions.

Key duties

• Coordinate and oversee discharge planning and transition of care.
• Schedule and confirm follow-up appointments and care-related services.
• Connect clients with relevant care programs and community resources.
• Collaborate with interdisciplinary teams to align care plans and needs.
• Educate patients and families on care plans, available resources, and next steps.
• Advocate for dignity, respect, and independence throughout the transition process.

Qualifications & Skills

• Strong communication and patient/family education skills.
• Ability to coordinate services and manage transition details accurately.
• Interdisciplinary collaboration and client-centered, compassionate approach.
• Advocacy mindset focused on safe, timely, and respectful care.