Care Transition Coordinator

Adoration Health•FAYETTEVILLE, GA

About The Position

The Care Transition Coordinator (CTC) facilitates patients’ 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. The CTC liaises among the agency, referral sources, and healthcare providers, supporting timely communication, documentation, and patient education. The position also carries out outreach strategies and sales-related administrative work to support market growth, financial stewardship, compliance, and patient satisfaction. The CTC evaluates patients and physician orders for home care eligibility, conducts face-to-face transitions, explains agency services and care orders, and coordinates transfer orders and ancillary services after acceptance. The role collaborates with agency leadership and clinical staff, communicates with referral and case management teams, and helps coordinate care when patients transfer to or return from a facility. It also includes sales administration, education of medical professionals, and protection of patient confidentiality.

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 and 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, managing sales and marketing expenses for financial stewardship and return on investment.
Implement weekly, monthly, and quarterly strategies to increase market share within assigned facilities.
Evaluate patients and physician orders for home care eligibility according to 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; educate patients on home care or hospice orders and services received 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 and align team efforts with referral-source and patient needs and expectations.
Perform sales administration duties, including BOA expense entry, following BOA policies and procedures, submitting payroll timesheets and PTO requests, participating in weekly 3LS meetings, attending required sales calls and company-provided in-services, and maintaining timely phone and email communication.
Educate patients about the importance of post-discharge physician appointments, obtaining necessary prescriptions before discharge, medication regimens, pharmacy use, and medication delivery methods.
Serve as liaison 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 the case management team with follow-up feedback 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.