LTSS Transition RN Coordinator - Clinician

LTSS Transition RN Coordinator – Clinician

DaMar Staffing Solutions – Indianapolis, IN

Salary Range: $75,000 – $90,000
Mileage Reimbursement Competitive Benefits Package

Position Overview

DaMar Staffing Solutions is seeking a compassionate, clinically strong, and highly organized LTSS Transition RN Coordinator – Clinician to support individuals transitioning across the continuum of care from inpatient and post-acute settings into community-based environments.

This role is primarily field-based and report to assigned hospital(s).

The LTSS Transition RN Coordinator serves as a clinical liaison, patient advocate, and care coordination partner working closely with LTSS Coordinators, providers, discharge planners, care teams, and community resources to ensure person-centered, high-quality care and reduce avoidable readmissions.

This position plays a critical role in improving health outcomes, supporting continuity of care, identifying barriers to successful transitions, and helping members safely remain in community settings whenever possible.

Position Details

• Primarily field-based role
• Monday–Friday schedule
• Standard business hours: 8:00 AM – 5:00 PM
• Travel required throughout assigned territory
• Mileage reimbursement provided

DaMar Staffing Solutions is actively hiring RNs located in or willing to support the following Indiana regions:

• Marion County

Key Responsibilities

Care Transition Coordination

• Conduct in-person, telephonic, and virtual outreach to members transitioning from inpatient or post-acute care settings
• Coordinate and support safe discharge planning and post-discharge follow-up
• Facilitate communication between hospitals, providers, LTSS teams, caregivers, and community agencies
• Participate in interdisciplinary case reviews and transition planning meetings
• Ensure alignment between member needs and Person-Centered Service Plans (PCSP)

Clinical Assessment & Care Planning

• Complete structured clinical assessments to evaluate post-discharge needs
• Identify barriers impacting successful transitions, including:
• • Medication access
  • Transportation
  • Durable medical equipment (DME)
  • Home health services
  • Caregiver support
  • Follow-up appointments
• Assist with development and implementation of individualized care plans
• Monitor member progress and escalate high-risk concerns when appropriate

Patient Advocacy & Member Support

• Build trusting relationships with members and families
• Educate members regarding:
• • Discharge instructions
  • Medication management
  • Community resources
  • Follow-up care
  • Preventive care strategies
• Advocate for timely access to medically necessary services and support systems
• Assist members in navigating healthcare and community-based resources

Utilization Review & Quality Support

• Review medical records and utilization data to identify care gaps and discharge barriers
• Support efforts focused on reducing avoidable ER visits and hospital readmissions
• Ensure compliance with CMS, NCQA, Medicaid, and state-specific transition-of-care requirements
• Maintain timely, accurate, and compliant documentation within care management systems
• Report critical incidents according to organizational and regulatory requirements
• Participate in audits, grievance processes, appeals, and quality improvement initiatives as needed

Collaboration & Leadership Support

• Collaborate with providers, LTSS coordinators, discharge planners, social workers, and interdisciplinary healthcare teams
• Provide mentorship and guidance to new staff members when needed
• Support operational improvement and transition-of-care best practices across assigned regions

Minimum Qualifications

• Active Registered Nurse (RN) license in the State of Indiana in good standing
• Minimum of 2 years of clinical nursing experience in one or more of the following:
• • Transitional care
  • Emergency department
  • Care management
  • Discharge planning
  • Home health
  • Skilled nursing
  • Utilization review
• Strong clinical assessment and care coordination skills
• Reliable transportation and ability to travel within assigned territory

Preferred Qualifications

• Experience working with Medicaid and LTSS populations
• Knowledge of NCQA, CMS, and transition-of-care standards
• Familiarity with utilization review and inpatient care coordination processes
• Strong communication and relationship-building skills
• Ability to work independently and manage a field-based schedule
• Experience documenting within electronic medical records or care management platforms
• Strong problem-solving and critical-thinking abilities
• Bilingual skills are a plus

Compensation & Benefits

• Competitive salary: $75,000 – $90,000 based on experience
• Mileage reimbursement
• Group Health Insurance
• Paid Time Off (PTO)
• Professional development opportunities
• Leadership and growth potential

Benefits & Perks

At DaMar, we are committed to supporting employees both professionally and personally. Employees have access to Paychex Flex Perks, which includes:

• Financial wellness tools, including earned wage access
• Voluntary insurance options (pet, home, auto, and more)
• Discounts on travel, entertainment, and retail
• Health and wellness resources
• Easy enrollment through payroll deduction

Why Join DaMar Staffing Solutions?

DaMar Staffing Solutions is committed to supporting healthcare initiatives that improve patient outcomes, strengthen care coordination, and promote community-based care solutions.

This role offers the opportunity to make a direct impact on vulnerable populations while working within a collaborative, mission-driven environment focused on quality care, patient advocacy, and operational excellence.

Apply today to learn more.