Transitional Care Navigator

Hometown Health; Reno, Northern (NV, KY); Hybrid; USD 70,000 - 95,000; Full time

Job summary

Hometown Health is seeking a Transitional Care Coordinator to pre-screen patients for rehab admissions and coordinate with the interdisciplinary team. You will evaluate patient needs, initiate screening forms, and ensure proper referrals to Renown facilities or services.

You will work closely with physicians, case managers, and discharge planners, educating families about rehabilitation options, CMS guidelines, and payer requirements to support optimal transitions of care.

Qualifications

• Must have working-level knowledge of the English language.
• Minimum of 5 years of clinical experience in an acute care and/or rehabilitation setting.
• Experience with physician and community referral development required.

Responsibilities

• Pre-screen patients for admission to rehabilitation or refer to appropriate services.
• Evaluate appropriateness of admission based on referral, patient needs, and payer guidance.
• Initiate pre-screen forms in acute care settings as appropriate.
• Communicate findings daily with Care Coordination and Transitional Care teams.
• Educate physicians, case managers, social workers, discharge planners, patients, and families about rehabilitation options.

Skills

Clinical experience

Discharge planning

Care coordination

Interdisciplinary teamwork

English proficiency

Education

English language knowledge

Tools

Microsoft Office

Outlook

Excel

Word

Job description

Hometown Health is seeking a Transitional Care Coordinator to pre-screen patients for rehab admissions and coordinate with the interdisciplinary team. You will evaluate patient needs, initiate screening forms, and ensure proper referrals to Renown facilities or services.

You will work closely with physicians, case managers, and discharge planners, educating families about rehabilitation options, CMS guidelines, and payer requirements to support optimal transitions of care.