Transitional Care Coordinator

Compensation: $25 - $35 / Hour

Benefits: 3 weeks paid time off (2 weeks + 6-7 federal holidays), 401K, Medical, Dental, and Vision.

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  Lead the transitional care process for assigned members from hospital discharge through 30-day post-discharge follow-up, ensuring no lapse in care continuity.
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  Review clinical documentation, discharge summaries, and hospital notifications to proactively identify follow-up needs, risk factors, and required interventions.
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  Initiate timely post-discharge outreach (within 24–48 hours) to patients or caregivers to complete medication reconciliation, confirm appointments, and assess home readiness.
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  Coordinate directly with hospitals, SNFs, home health, PCP offices, and community providers to ensure discharge orders and services are executed appropriately and without delay.

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  2 years experience in transitional care (Preferred)
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  Bilingual (Strongly Preferred)
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  Bachelor’s degree (Added Plus)