The Transitional Care Coordinator plays an integral role in supporting CarDon's Transitional Care Program and ensuring a coordinated transition for residents across the continuum of care.

This position works collaboratively with the Transitional Care Clinical Manager (TCCM), community Social Services teams, interdisciplinary team members, hospital partners, home health agencies, and other post-acute partners to support effective transitions, reduce barriers to discharge, and maintain continuity of care following a resident's transition home.

The Transitional Care Coordinator and Transitional Care Clinical Manager will work closely together to coordinate program responsibilities and workflows, with each role bringing a different area of focus to the overall success of the program.

Key Responsibilities

Transitional Care Coordination & Referral Management

• Support the day-to-day coordination of the Transitional Care Program across participating CarDon communities.
• Review and assist with management of Transitional Care referrals and ensure appropriate follow-through.
• Assist with coordinating services and resources needed to support a successful transition from the community to home.
• Maintain communication with appropriate internal and external partners throughout the transition process and be a point of contact for our home health, hospice and post acute ACO partners post discharge.

Post-Discharge Support

• Support ongoing communication and follow-up with residents after discharge as part of the Transitional Care Program.
• Assist in coordination of post-discharge needs, barriers, or concerns and help connect residents with appropriate resources and members of the care team.
• Communicate identified concerns to the appropriate CarDon team member, provider, home health agency, or other care partner to promote timely intervention.
• Help maintain continuity between the resident, CarDon community, and post-discharge care partners.
• Be a point of contact when residents need to return back to facility to avoid rehospitalization.

Social Services Support & Education

• Serve as a resource and support to community Social Services teams related to Transitional Care Program processes and expectations.
• Assist with education and reinforcement of Transitional Care workflows, referral processes, and discharge coordination.
• Collaborate with Social Services teams to identify opportunities to strengthen discharge planning and transition-of-care processes.
• Promote consistent communication and coordination across participating communities.

Care Coordination Platforms & Documentation

• Utilize MatrixCare and electronic care coordination platforms, such as Olio and Watershed, to support communication, referrals, and transitional care workflows.
• Monitor relevant platform activity and assist with timely follow-up and communication.
• Maintain accurate and timely documentation related to Transitional Care activities.
• Help ensure appropriate visibility and communication among CarDon communities and external care partners.

Collaboration & Program Support

• Work closely and collaboratively with the Transitional Care Clinical Manager to coordinate duties, responsibilities, workflows, and program priorities.
• Partner with community leadership, nursing, Social Services, therapy, providers, home health agencies, and other care partners to support successful transitions.
• Participate in Transitional Care meetings, education, and program initiatives.
• Assist with identifying trends, barriers, and opportunities for improvement within the Transitional Care Program.
• Support program growth and consistency as Transitional Care expands across CarDon communities.

Qualifications

• Background in social services, healthcare, care coordination, case management, discharge planning, or a related field preferred.
• Experience in skilled nursing, long-term care, hospital, home health, hospice, or other post-acute healthcare settings preferred.
• Strong communication, organization, and relationship-building skills.
• Ability to collaborate effectively with interdisciplinary teams and external healthcare partners.
• Comfortable utilizing electronic health records and technology-based care coordination platforms.
• Ability to manage multiple priorities and follow through on time-sensitive needs.
• Understanding of discharge planning, community resources, and transitions of care preferred.
• Ability to review data and trending to initiate process improvement.
• Understanding ACO's and Value Based Care programs preferred.

Ideal Candidate

The ideal candidate is organized, collaborative, relationship-focused, and passionate about helping residents successfully transition through the healthcare continuum. This individual should be comfortable working across multiple CarDon communities and with a variety of internal and external partners while helping create consistency, communication, and connection throughout the Transitional Care Program. Building strong relationships and having a collaborative spirit will be important piece to this role.