Care Transition Coordinator

Adoration Health•FAIRFAX, VA

27d•$80,000 - $90,000

About The Position

The Care Transition Coordinator (CTC) facilitates patient transitions from healthcare facilities to home health or hospice care. The role evaluates patient eligibility, coordinates care plans, and arranges services—including durable medical equipment (DME) and infusion—in accordance with agency protocols and patient needs. Acting as a liaison between the agency, referral sources, and healthcare providers, the CTC supports timely communication, documentation, and patient education. The role also carries out strategic outreach and sales administration to support market growth, financial stewardship, compliance, and patient satisfaction through personalized care transitions.

Requirements

At least one year of experience in home health or hospital-based case management.
Current, active licensure in the state of practice as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker (SW), or Physical Therapist (PT).
Valid driver's license, reliable transportation, and current auto insurance.
Demonstrated understanding of home health eligibility criteria and Medicare/insurance coverage guidelines.

Nice To Haves

One to three years of experience in medical marketing or healthcare business development.
Respiratory Therapist (RT) certification and/or completion of a technical clinical program demonstrating strong clinical knowledge.

Responsibilities

Achieve monthly personal production goals and Medicare-certified admission targets for assigned locations, while managing sales and marketing expenses responsibly.
Implement weekly, monthly, and quarterly strategies to increase market share within assigned facilities.
Evaluate patients and physician orders for home care eligibility in accordance with Right of Choice guidelines.
Conduct face-to-face patient transitions, educate patients about the agency, and identify the primary care physician responsible for the plan of care.
Present identified patient needs to the Executive Director for branch approval and acceptance, and complete CTC encounter documentation in Home Care Home Base.
After patient acceptance, coordinate transfer orders and ancillary services such as DME and infusion, and educate patients on home care or hospice orders and services from the referral source.
Ensure needs identified by referral sources are documented and addressed by the agency upon acceptance.
Collaborate with the Executive Director and Clinical Director to promote growth in alignment with referral-source and patient needs and expectations.
Perform sales administration duties, including BOA expense entry, compliance with BOA policies and procedures, payroll timesheet submission, participation in weekly 3LS meetings, PTO requests, and attendance at required sales calls and company-provided in-services.
Maintain timely communication by phone and email.
Educate patients about the importance of post-discharge physician appointments, obtaining prescriptions before discharge, medication regimens, pharmacy use, and delivery methods.
Liaise between the agency and healthcare providers for newly referred patients and existing patients transferred from home health services to hospitals.
Notify discharge planning when active home health patients transfer to a facility, and coordinate resumption of care before discharge when applicable orders are obtained.
Provide follow-up feedback to the case management team about readmission status and non-admit decisions based on information provided by the agency.
Maintain patient confidentiality in accordance with applicable laws and agency policies.
Demonstrate knowledge of agency services, competitive advantages, specialty programs, and Medicare guidelines, and educate medical professionals using appropriate tools and literature.