Transitional Care Professional

Your Health Organization; Pooler (GA); On-site; USD 42,000 - 70,000; Full time

Benefits offered by this job

Vehicle allowance

401K matching

PTO

Job summary

Your Health Organization is seeking a Transitional Care Professional to coordinate patient care as they transition from hospital to home in the Savannah area. The role involves home and facility visits, collaboration with care teams, and arranging post-discharge services to prevent readmissions.

The position requires reliable transportation and full-time schedule with 8‑hour shifts, Monday to Friday, 8am–5pm. Experience in public health or home health is preferred.

Qualifications

• Strong interpersonal and written communication skills.
• Ability to multitask and prioritize responsibilities.

Responsibilities

• Visit referrals and patients within assigned facilities.

Skills

Communication

Customer service

Time management

Organization

Education

Certified Medical Assistant

Paramedic

Licensed Nurse

Tools

AthenaText

EHR systems

Job description

Career Opportunities with Your Health Organization

A great place to work.

Current job opportunities are posted here as they become available.

We are seeking a qualified candidate to act as the clinical liaison for our patients throughout the Savannah area.

The Transitional Care Professional position plays a crucial role in facilitating a smooth transition for patients from hospitals, rehabilitation centers and skilled nursing facilities to their homes by providing comprehensive care coordination and support. The Transitional Care Professional plays a vital role in enhancing the patient experience and reducing hospital readmissions.

Transitional Care Professional perform visits in homes and facilities (ALF and ILF's) in their designated service area.

You must have reliable transportation as travel is required daily. This is a full time, salary‑based working 8‑hr shifts Monday‑Friday (8am‑5pm).

The following service area(s) are currently available:

(Details to be added.)

About

We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. Committed to excellence and innovation, our team collaborates closely with facilities and families to ensure accessible, coordinated, and compassionate care.

Why Choose a Career at Your Health?

Providing high quality care for our patients is the center of what we do, and we provide the same care for our employees. Here are some of the benefits that are available to our employees.

• Competitive Compensation Package with Bonus Opportunities
• Employer Matched 401K
• Free Visit & Prescriptive Services with HDHP Insurance Plan
• Employer Matched HSA
• Generous PTO Package
• Vehicle allowance

What Are We Looking For?

Your Health is currently looking for a Transitional Care Professional to join our growing primary care family. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

The following is a list of essential functions, which may be subject to change at any time and without notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).

Area of Responsibility:

• Visit the Company’s referrals and established patients within assigned facilities.
• Establish trust and rapport with patients to assist them in making informed decisions regarding their health during their stay in the facility.
• Provide guidance and feedback to patients based on recommendations from the care team regarding their care.
• Ensure a seamless transition for patients returning home by arranging the necessary services, such as home health, outpatient rehab, and follow‑up care with the Company’s providers and support staff.
• Ensure all essential visits are scheduled including those with the Company’s primary care provider, virtual provider, specialists, pharmacists, social workers, etc.
• Facilitate effective communication between healthcare professionals involved in the patient’s care.
• Ensure patient and family adherence to the plan of care.
• Interact with patients via phone, email, patient portal, telephone, AthenaText, in person, etc. to gather necessary information.
• Provide exceptional customer service to patients, exhibiting a compassionate and empathetic attitude and a patient‑centered approach to care. Address patient concerns, inquiries, and complaints professionally and promptly, striving to meet patient needs and ensure their satisfaction.
• Perform general administrative tasks and support other staff as needed.
• Utilize the company’s software systems to enhance patient care and staff efficiency.
• Must be available during normal work hours (unless previously approved by direct supervisor).
• Utilize the company’s software systems and update information as required.
• Participate in coaching calls.
• Perform other duties as requested or required, in the sole discretion of the Company.

Qualifications:

• Certified Medical Assistant, Paramedic, or Licensed Nurse preferred. Certifications or licenses must be in good standing.
• Previous experience in public health or home health preferred.
• A minimum of three (3) years clinical experience preferred.
• Demonstrated ability to supervise and direct professional and administrative personnel.
• Ability to read and communicate effectively.
• Strong written and verbal skills.
• Strong organizational and time management skills, with the ability to multitask and prioritize responsibilities effectively.
• Basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills.
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
• Ability to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.