Transitional Care Coordinator - HomeCare

The Transitional Care Coordinator serves as a vital link between patients, caregivers, healthcare providers, and community resources to ensure safe and effective transitions across the post-acute care continuum. This role collaborates with hospitals, skilled nursing facilities, assisted living communities, physicians, and home care teams to support patients transitioning from one level of care to another while reducing readmissions and improving patient outcomes. The position also focuses on relationship-building, referral development, and strategic partnership growth.

Key Responsibilities

• Collaborate with hospital case managers, social workers, physicians, and post-acute care providers to coordinate seamless patient transitions.
• Review patient demographic and clinical information to ensure accurate care planning and continuity of care.
• Conduct bedside visits with patients and caregivers to assess needs, identify barriers to discharge, and provide education.
• Evaluate health literacy and utilize teach-back methods to reinforce understanding of care plans and disease management.
• Coordinate post-discharge services, equipment, medications, and follow-up appointments.
• Identify high-risk patients and implement strategies to prevent avoidable readmissions.
• Educate patients and families regarding home health services, disease management, warning signs, and available community resources.
• Serve as a liaison between healthcare teams, patients, caregivers, and referral sources.
• Participate in care conferences, interdisciplinary rounds, and family meetings as needed.
• Develop and maintain relationships with hospitals, skilled nursing facilities, assisted living communities, and physician partners.
• Support referral growth initiatives and promote home health and related service lines.
• Maintain accurate documentation and ensure compliance with HIPAA and all regulatory requirements.

Required

• Minimum of 1 year of recent home care and/or sales/marketing experience.
• Strong communication, relationship-building, and organizational skills.
• Computer proficiency.
• Ability to work collaboratively across multiple healthcare settings.
• English speaking.

Preferred

• Associate's or Bachelor's degree.
• Active Connecticut RN or LPN license may be required for certain hospital-based positions.