Transitional Care Coordinator

Registered Nurse (RN) or Medical Social Worker

The Transitional Care Coordinator is a key leader in coordinating safe, effective transitions of care for patients and their families. This position oversees the assessment, planning, coordination, implementation, and evaluation of transitional care services from pre-admission through discharge and transition back to the community or next level of care.

Working closely with the Medical Director, providers, nursing, therapy, social services, case management, and other members of the healthcare team, the Transitional Care Coordinator helps ensure that patients receive the right services at the right time while reducing barriers to successful transitions.

This position is well suited for an experienced Registered Nurse or Medical Social Worker with a strong background in case management, discharge planning, care coordination, utilization management, or post-acute care.

• Provides leadership for the Transitional Care Program in collaboration with the Medical Director, Director of Nursing and interdisciplinary care team.
• Coordinates program implementation, patient care, referral development, staff education, and quality improvement activities.
• Maintains knowledge of applicable Transitional Care Program processes, clinical guidelines, payer requirements, and CMS requirements.
• Serves as a resource to staff, providers, patients, and families regarding transitional care services.
• Provides education and orientation to employees regarding the Transitional Care Program.
• Coordinates and leads weekly interdisciplinary team rounds and utilization review meetings.
• Promotes effective communication and collaboration across disciplines and throughout the continuum of care.

• Coordinates care from referral and pre-admission through discharge and transition to the next level of care.
• Conducts or coordinates assessments to identify patient and family needs, barriers to discharge, available supports, and potential risks for readmission.
• Develops and coordinates individualized transition and discharge plans with patients, families, providers, and the interdisciplinary care team.
• Helps patients and families navigate healthcare services and available community resources.
• Provides discharge planning support for acute care patients as needed.
• Identifies potential barriers to successful transitions and works with the care team to address those barriers.
• Facilitates communication among patients, families, providers, referring facilities, and community partners.
• Advocates for patient-centered plans that reflect individual goals, needs, preferences, and available resources.

• Reviews referrals and evaluates appropriateness for the Transitional Care Program.
• Works with providers and interdisciplinary team members to determine whether GCMC can safely and appropriately meet the patient's needs.
• Collaborates with discharge planners, case managers, social workers, and other referral partners at acute care hospitals.
• Coordinates required skilled nursing, therapy, or other services prior to admission.
• Ensures an appropriate payer source has been identified and collaborates with business office staff regarding coverage.
• Maintains working knowledge of Medicare and other payer requirements applicable to transitional and skilled care.
• Identifies risk factors for readmission and works with patients, families, and care team members to mitigate identified risks.
• Visits prospective patients in acute care settings during the referral/intake process when appropriate.

• Monitors Transitional Care Program quality measures and outcomes.
• Ensures required program and quality data are collected and reported.
• Participates in the development and implementation of improvement plans when opportunities are identified.
• Helps maintain program policies, procedures, clinical resources, and process guidelines.
• Evaluates opportunities to strengthen or expand transitional care services based on the needs of patients and the community.
• Participates in ongoing development of the Transitional Care Program.

• Develops and maintains strong working relationships with hospitals, discharge planners, case managers, social workers, providers, and other referral partners throughout the region.
• Participates in outreach and referral-development activities to…