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Transition Care Coordinator

Sentara Healthcare
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Full Time
Experience:
Avoidant Personality Disorder
Aging
ECT
Individuals
In-patient Non-Psychiatric
In-patient Psychiatric

About Job

Department and Name: Care Management – SHP VA- Health Plan
Physical Location: Roanoke, VA
Employment Status: Regular
Shift: First (Days)
Posted Date: May 6, 2025

Sentara Health Plans is hiring a Transition Care Coordinator for the Health Care Services Department.

This is a remote position however traveling to Nursing Facilities and Members Home is required in Roanoke and surrounding areas in Virginia.

The Regional Transition Care Coordinator (TCC) is responsible for managing and supporting all transitional care and post-acute services to members in a geographical region. Care transitions include transitioning individuals from Nursing Facilities, hospitals, inpatient rehabilitation, or other institutional settings into the community, and assisting individuals who desire to remain in their community setting. The TCC will work in collaboration with the Care Coordinator, Interdisciplinary Care Team Meetings, and facilities to facilitate a safe and effective transition. The TCC will plan, coordinate, monitor, and evaluate options to meet the individual's needs prior to transition back out into the community-based setting. The TCC will ensure a smooth hand off is given to the receiving Care Coordinator assigned to the individual.

Education:

One of the following licenses or education is required: RN, LPN, or bachelor’s degree in health & human services. LCSW or LPC licensure also acceptable for certain positions

Experience:

  • Requires a minimum of two (2) years of Case Management Experience or Long-Term Care Experience.
  • Nursing, Social Work or Human Service Field.
  • One year working with Medicaid or CCC Plus populations, licensed in the state of VA.

Professional Field

professional badgeCounseling
professional badgeNursing
professional badgeSocial Work
professional badgeOther Behavioral, Mental, or Healthcare Field

Patient Focus

Diagnoses

Avoidant Personality Disorder

Issues

Aging

Therapeutic Approach

Methodologies

ECT

Modalities

Individuals

Practice Specifics

Settings

In-patient Non-Psychiatric
In-patient Psychiatric
Milieu
Research Facilities/Labs/Clinical Trials
Residential Treatment Facilities (RTC)
Substance Abuse Treatment Facilities
Telehealth/Telemedicine
Home Health/In-home