Reporting to the Access Solutions Manager, the Care Transitions Coach provides a structured, person-centered intervention to individuals transitioning from a hospital or other inpatient setting to the community. The Coach helps participants and their caregivers build the knowledge, confidence, and self-management skills needed to navigate the post-discharge period, follow the discharge plan, recognize warning signs, communicate effectively with healthcare providers, and connect with needed community resources. The position delivers the approved Care Transitions Intervention workflow, completes required contacts within established timeframes, documents all activities accurately, and works collaboratively with hospital partners, healthcare providers, caregivers, and internal CoAction teams.

Care Transitions Intervention

•     Receive and review referrals from hospital and healthcare partners and initiate outreach within established program timeframes.

•     Engage eligible participants and caregivers, explain the Care Transitions program, obtain required consent, and establish a collaborative coaching relationship.

•     Complete the required facility-based or pre-discharge contact, home visit, and follow-up telephone contacts during the 30-day intervention period.

•     Use person-centered coaching techniques to support participant goals, preferences, strengths, cultural needs, and self-determination.

•     Guide participants through the program's core transition areas, including medication self-management, use of a personal health record, timely medical follow-up, and recognition of condition-specific warning signs.

•     Help participants prepare questions for healthcare appointments, organize health information, and strengthen communication with physicians, pharmacists, and other members of the care team.

•     Reinforce the participant's discharge instructions without providing medical advice, diagnosing conditions, changing medications, or replacing the role of licensed healthcare professionals.

Assessment, Resource Coordination, and Follow-Up

•     Identify barriers that may interfere with a safe transition, including transportation, food access, housing instability, caregiver stress, medication access, health literacy, and other health-related social needs.

•     Provide information, referral, and warm handoffs to CoAction programs and community services that support the participant's transition goals.

•     Coordinate with hospital discharge planners, primary care offices, pharmacies, home health agencies, caregivers, and community providers as authorized by the participant.

•     Escalate urgent health or safety concerns according to program protocols, including contacting emergency services or the appropriate clinical provider when indicated.

•     Track participant progress throughout the intervention and support successful completion, transfer, or closure of services.

Documentation, Quality, and Compliance

•     Complete accurate, timely, and objective documentation of each participant contact, attempted contact, referral, intervention, outcome, and case closure.

•     Maintain complete records in the designated electronic documentation system and comply with all partner, payer, contract, and agency reporting requirements.

•     Protect participant confidentiality and comply with HIPAA, agency privacy and security policies, and minimum-necessary information standards.

•     Meet established productivity, timeliness, contact-completion, and quality benchmarks.

•     Participate in case review, quality assurance, chart audit, performance improvement, and corrective action activities as required.

•     Collect required program data and outcome measures to support contract reporting, evaluation, and continuous improvement.

Collaboration and Professional Responsibilities

•     Develop and maintain effective working relationships with participants, caregivers, hospital partners, healthcare providers, community organizations, and CoAction staff.

•     Participate in staff meetings, supervision, required training, case consultation, and ongoing competency development.

•     Complete approved Care Transitions Coach training and demonstrate fidelity to the program model and established workflows.

•     Maintain reliable transportation and travel throughout the assigned service area for hospital, facility, and home-based visits.

•     Demonstrate professionalism, sound judgment, flexibility, cultural humility, and respect in all participant and partner interactions.

•     Actively support CoAction's mission, vision, values, and commitment to person-centered services.

•     Perform other duties as assigned.