Transitions Specialist & Onboarding Liaison

Bluestem PACE is looking for a full-time Transition Specialist & Onboarding Liaison to join our team!

Join our team and enjoy outstanding benefits!

At Bluestem Communities, we value our full-time team members and offer a benefits package designed to support both your personal and professional well-being. As a full-time employee you can enjoy the following benefits:

Health and insurance

Health, dental and vision insurance

Flexible Spending Accounts (medical & childcare available)
AFLAC products

Voluntary life insurance

Financial wellness
401(k) plan with company match

Gradifi student loan payment program

Payactiv:
Early access to earned wages

Company-paid benefits

Group term life and AD&D insurance

Short-term disability insurance

Employee Assistance Program (EAP)
Time off and perks

Paid Time Off (PTO) and six (6) paid holidays

Bluestem Wellness Center membership

Meal discounts at our dining locations

Our benefits are designed to help you thrive both personally and professionally. Explore the full range of benefits and learn more about how Bluestem Communities can be the right fit for you—visit our Careers page today!

Position Overview:

The Transition Care Specialist & Onboarding Liaison serves as the central point of coordination for supporting participant transitions across care settings while onboarding new employees. This role facilitates effective communication, ensures seamless integration of new team members, and promotes continuity of care for participants by coordinating transitions between hospitals, skilled nursing facilities, home care, and the PACE center. The position works collaboratively with interdisciplinary team members, community partners, participants, caregivers, and leadership to ensure a positive onboarding experience and successful care transitions.

Essential Job Functions:

Transition Care Responsibilities:

Initiate and manage Transition Work Plans for all participant transitions, including new enrollees, emergency room visits, hospitalizations, respite stays, and discharges to home.

Audit Transition Work Plans to ensure compliance and effectiveness, providing education, guidance, and follow-up with IDT members as needed.

Communicate with participants, caregivers, providers, and community partners to facilitate safe and timely transitions.

Review discharge plans and ensure follow-up services are arranged.

Monitor the EMR after transitions to identify barriers, gaps in care, or potential readmission risks.

Ensure required documentation is completed accurately and on time.

Educate participants and caregivers regarding care plans, follow-up appointments, medications, and available resources.

Track transition outcomes and identify opportunities to improve participant experience and quality outcomes.

Participate in quality improvement initiatives related to care coordination and transitions.

Coordinating home visits for transition coordination to discharging participant home from respite.

Onboarding Liaison Responsibilities Serve as the primary contact for newly hired employees from offer to acceptance through completion of orientation.

Coordinate onboarding activities, orientation schedules, and department introductions.

Ensure completion of onboarding requirements, including training assignments, policy acknowledgments, and required documentation.

Communicate regularly with new hires to answer questions and provide support during the onboarding process.

Collaborate with Human Resources, department leaders, and educators to facilitate a smooth transition into assigned roles.

Monitor onboarding progress and follow up on outstanding requirements.

Coordinate welcome activities and promote employee engagement during orientation and onboarding.

Track onboarding metrics and identify opportunities for process…