LPN Transition of Care Coordinator

Job Title:

Transitions of Care Coordinator (Primary Care)
Position Summary The Transitions of Care Coordinator is responsible for ensuring safe, timely, and effective transitions of patients between healthcare settings, including hospital discharges, emergency department visits, and post-acute care. This role focuses on reducing readmissions, improving patient outcomes, and supporting continuity of care through patient outreach, care coordination, and collaboration with the primary care team.

Key Responsibilities Coordinate care for patients transitioning from hospitals, skilled nursing facilities, or other care settings back to primary care Perform timely post-discharge outreach (e.g., within 24–72 hours) to assess patient needs, medication adherence, and follow-up care Schedule and confirm post-discharge appointments with primary care providers

Conduct medication reconciliation in collaboration with providers and pharmacists

Identify and address barriers to care, including transportation, social determinants of health, and access to medications

Educate patients and caregivers on discharge instructions, treatment plans, and warning signs

Collaborate with physicians, nurses, case managers, specialists, and community resources to ensure coordinated care Track and monitor high-risk patients to reduce hospital readmissions and emergency department utilization

Maintain accurate and timely documentation in the electronic health record (EHR)
Support quality improvement initiatives related to care transitions and population health

Qualifications

Education & Experience Minimum 2–3 years of experience in care coordination, case management, or primary care setting

Licensed Practical Nurse (LPN) required

Active and unrestricted license/certification in Arkansas (as applicable)
Skills & Competencies Strong understanding of care transitions, discharge planning, and chronic disease management

Excellent communication and patient engagement skills

Ability to work collaboratively in a multidisciplinary team Knowledge of community resources and social services

Strong organizational skills and attention to detail

Proficiency with EHR systems and care management tools

Key Performance Indicators (KPIs)
Timeliness of post-discharge patient contact

Completion rate of follow-up visits within recommended time frames

Accuracy and completeness of documentation
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