Care Transition Coordinator, RN

There’s home care and then there’s Bay Care Homecare! At Bay Care, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that’s built on a foundation of trust, dignity, respect, responsibility and clinical excellence.

• Facility:
  Bay Care Health System, Care Coordination East
• Location:
  
  Homecare Largo
• Status:
  Full Time, Exempt:
  Yes
• Shift
  
  Hours:
  
  8:00 AM - 5:00 PM
• Weekend Work:
  Every 3rd
• On Call:
  No
• Hybrid

• Benefits (Health, Dental, Vision)
• Paid time off
• Tuition reimbursement
• 401k match and additional yearly contribution
• Yearly performance appraisals and leadership award
• Community discounts and more
• Relocation assistance if eligible
• AND the Chance to be part of an amazing team and a great place to work!

• Provide education of homecare services to community groups and physicians.
• Collaborate with business development team in gaining and maintaining market share through referral intake process.
• Collaborate with referral sources in transitions of care.
• Timely communication with all referrals sources telephonically as well as through electronic platforms.
• Provide clear concise referral provided to homecare division meeting all regulatory, payer, and safety requirements.
• Completion of preadmission assessment and education to patient and caregiver of homecare services.
• Coordination of Homecare and Pharmacy as well as communication with referral sources and physicians.
• Responsible for knowledge of Medicare and Managed Care regulations and requirements.
• Timely response to referrals sources, providers, and leadership is essential.
• Responsible for documenting face to face encounter, verifying POC and following Physicians which is a condition of payment.
• Oversight of Care Coordination Assistant team.
• Identifies patients appropriate for disease management programs and telehealth.
• Performs ICD-10 coding of referrals.
• Identifies potential MSP scenarios.
• Responsible for leading MDI huddles on rotation basis.
• Monitors and communicates referral source activity acting as one point of contact for referral sources, home health, and infusion.
• Will be responsible for additional transitions of care duties as assigned.

• Active/Clear Florida RN license is required.
• Required Associate's Nursing or Diploma Nursing
• CCMC Certification preferred
• Preferred Bachelor's Nursing
• Preferred 3 years Nursing
• Preferred 1 year Home Care

This position requires Level II screening through the Florida Care Provider Background Screening Clearinghouse, managed by the Agency for Health Care Administration (AHCA). More information can be found at

Equal Opportunity Employer Veterans/Disabled