Transitions Coordinator

Brio Living Services; Ypsilanti Charter Township (MI); On-site; USD 60,000 - 70,000; Full time

Benefits offered by this job

Flexible time off

Medical, Vision & Dental Insurance

Retirement Savings Plan

Daily Pay

Referral Bonus $500

Tuition assistance

Wellness reimbursement

Mileage reimbursement

Job summary

Brio Living Services in Ypsilanti, MI seeks a Transitions Coordinator to advocate for participants and ensure smooth, safe transitions across the care journey. You will work with hospitals, facilities, families, and the IDT to coordinate admissions, discharges, and ongoing care transitions.

The role emphasizes proactive problem solving, continuity of care, and strong collaboration with providers to minimize gaps in services.

Qualifications

• Bachelor’s degree in Social Work or Nursing preferred.
• Minimum of 1 year experience working with frail elderly population.
• Experience in case management, care coordination, hospital discharge planning, home health, skilled nursing, long-term care, or PACE desired.
• Excellent verbal and written communication skills; ability to collaborate with participants, families, providers.

Responsibilities

• Coordinate participant care as patients move between hospitals, nursing facilities, rehab centers, and home.
• Share participant information with healthcare providers to ensure smooth transitions.
• Work with IDT, physicians, and facility staff to plan safe discharges.

Skills

Bachelor's degree required

1 year minimum experience

Case management

Care coordination

Discharge planning

Communication skills

Driver's license

CPR certification optional

Education

Bachelor's degree in Social Work or Nursing preferred

Job description

Transitions Coordinator

Department: Direct Care

Employment Type: Full Time

Location: Ypsilanti, Mi

Reporting To: Jennifer Calvert

Compensation: $60,000 - $70,000 / year

Description

Schedule: Full time exempt, minimum 40 hours per week | Monday - Friday | 8:00 am - 4:30 pm

Department: Direct Care | Huron Valley PACE | Ypsilanti, MI

The Transitions Coordinator is a vital advocate for participants, ensuring every transition in care is smooth, safe, and seamless. Working closely with hospitals, rehabilitation centers, long-term care facilities, participants, families, and the Interdisciplinary Team (IDT), this role coordinates every step of the care journey to promote exceptional outcomes. From admissions and discharges to ongoing care transitions, the Transitions Coordinator champions continuity of care, proactively addresses participant needs, and helps eliminate gaps in services.

Key Responsibilities

Care Transition Coordination

• Coordinates participant care as they move between hospitals, nursing facilities, rehabilitation centers, and home.
• Shares important participant information with healthcare providers and facilities to ensure smooth transitions and continuity of care.
• Works with the Interdisciplinary Team (IDT), physicians, and facility staff to plan safe and effective discharges.

Participant Care and Support

• Visits participants in hospitals, nursing facilities, and homes to assess needs and provide support.
• Participates in hospital and nursing facility rounds to monitor participant health and progress.
• Monitors services provided in contracted facilities to ensure participants receive quality care.

Team Collaboration and Communication

• Maintains regular communication with hospitals, nursing facilities, healthcare providers, and the IDT regarding participant care.
• Shares updates on participant status and discharge plans with team members.

Quality and Compliance

• Reviews services and healthcare utilization to ensure participants receive appropriate care.
• Participates in quality improvement activities related to care transitions and participant outcomes.
• Maintains current knowledge of healthcare regulations, processes, and best practices.

Documentation and Record keeping

• Accurately documents participant care and coordination activities in the electronic medical record (EMR).
• Completes required transition of care notes in a timely manner.
• Complies with all organizational policies and applicable federal and state regulations.

Additional Responsibilities

• Travels regularly between PACE centers, participant homes, hospitals, skilled nursing facilities, and other locations throughout the service area.
• Performs other duties and responsibilities as assigned within the scope of practice and role.

The above is a summary of the position, it in no way states or implies that these are the only duties this position will be required to perform. If selected for the position you will receive a full job description.

Skills, Knowledge & Expertise

• Bachelors Degree in Social Work or Nursing preferred.
• Minimum of 1 year experience working with the frail elderly population.
• Experience in case management, care coordination, hospital discharge planning, home health, skilled nursing, long-term care, or PACE strongly desired.
• Excellent verbal and written communication skills, with the ability to effectively collaborate with participants, families, healthcare providers, and community partners.
• Position requires the ability to lift and move objects weighting up to 35 pounds without assistance.
• Valid Michigan driver's license, reliable transportation, and proof of automobile insurance.
• CPR certification or willing to obtain within 6 months of employment

Job Benefits

• Generous 6 weeks of Flexible time off per year—plus paid holidays on top of that.
• Competitive Benefits for Full-Time Team Members – Enjoy Medical, Vision & Dental Insurance starting on the 1st of the month after 30 days of hire.
• Retirement Savings Plan – Secure your future with employer contributions.
• Daily Pay –Instantly transfer your daily earnings.
• Team Member Referral Bonus Program – Earn $500 when you bring great people to our team!
• Career Growth & Development – Advance your career with tuition assistance and school scholarships up to $3,000 per semester.
• Wellness Program & Reimbursement – Prioritize your health and well-being, reimbursed 120 a year!
• Mileage Reimbursement – Offered for work-related travel.

ACCESSIBILITY SUPPORT

Brio Living Services is committed to offering reasonable accommodation to job applicants with disabilities. If you need assistance or an accommodation due to disability, please contact us at [e-mail]

BRIO LIVING SERVICES IS AN EQUAL OPPORTUNITY EMPLOYER

Brio Living Services provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, or genetics in accordance with applicable federal, state and local laws.