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Patient Transition Coordinator

Residential Home Health and Hospice
Lewisburg, PA Full Time
POSTED ON 7/23/2026
AVAILABLE BEFORE 11/19/2026

The Patient Transitions Coordinator is responsible for initiating care transitions for patient referrals requiring home health, hospice, or palliative services. The role may include explaining benefits, gathering information towards the determination of eligibility, and attend family and facility meetings when appropriate. The Patient Transitions Coordinator will work with Hospital staff, the post-acute community, and the company's Sales, Nurse Liaisons and Integration staff to maintain professional referral source relationships and achieve positive outcomes.

Patient Transitions Coordinator Responsibilities:


  • Initiates contact for the company's Home Health, the company's Hospice, or the company's Palliative to assists in preparation of accepting care of the patient such as obtaining complete/accurate demographic information, medical history including diagnosis for care, and primary care physician information.
  • Responsible for introducing the company's Home Health, explaining benefits, and coordinating clinical information to start care for the physician ordered service.
  • Assist Sales team with referral cooordination including the following, but not limited to:
  • Assist with obtaining physican signatures

  • Assist with pulling informations from EMR's for complete referrals

  • Calling facilities and asking them to send over more details

  • Complete bedside meetings with discharging patients

  • Provides follow up feedback to referral sources regarding admissions and any non-admit decisions.
  • Collaborates with the rehabilitation facilities regarding patient care needs and discusses potential needs of services at discharge.
  • Assist in systems integration and process improvements which result in improved patient outcomes and transitions of care.

Patient Transitions Coordinator
Requirements:

  • Demonstrated knowledge of referral source types and community resources
  • Must have excellent organizational skills and ability to complete competing priorities
  • High energy level and passionate about care delivery
  • Displays a high level of professionalism by exercising appropriate communication, patience, flexibility and a cooperative attitude
  • Ability to listen attentively and offer care options based on individual patient health needs
  • Proficient computer skills – ability to navigate Microsoft email, word, excel, and agency software.
  • Minimum of two years of experience in a home health setting and/or discharge planning preferred.
  • Sales experience preferred


CERTIFICATES, LICENSES, REGISTRATIONS:

Must have and maintain a valid Pennsylvania Driver's License, maintain automobile insurance coverage and have access to a reliable automobile.


PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, climb stairs, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.


The employee frequently lifts and/or moves up to 20 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.


WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this position, the employee travels by automobile and is exposed to changing weather conditions. Employee will be required to drive daily for meetings or to complete daily work responsibilities. Employee will work in varied the company's and facility environments based on assigned caseload.

COMMENTS:

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.

About Graham Healthcare Group:

As an innovator in an evolving healthcare world, Graham Healthcare Group has been designing business and technology solutions to drive better care, outcomes, and productivity within its own home health and hospice companies for over 20 years. In the last several years, our solutions have been successfully integrated across the healthcare continuum.

Join the Graham Healthcare Group and enjoy the following benefits:

  • Competitive Pay: With opportunity for advancement

  • Health and Welfare Benefits: Various medical, dental, and vision insurance options for you and your family to choose from.

  • Supplemental Benefits: Company paid life insurance and disability benefits. Also, pre-tax FSA and HSA plans are offered.

  • Generous PTO Packages.

  • Retirement: Save for your future with our company offered 401k plan and pension.

  • Company-Paid Education Programs: Grow your career by taking advantage of 50% discounts on tuition for selected courses offered by Purdue and Kaplan.

Benefits may vary based on your employment status.

NOTICE: Successful completion of a drug screen prior to employment is part of our background process, which includes medical and recreational marijuana.

By supplying your phone number, you agree to receive communication via phone or text.

By submitting your application, you are confirming that you are legally authorized to work in the United States.

JR# JR256991

Salary.com Estimation for Patient Transition Coordinator in Lewisburg, PA
$86,032 to $107,798
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