Transitional Care Navigator: Smooth Discharges & Care Coordination

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

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.