Care Transition Coordinator

BrightSpring Health Services•Florence, SC

About The Position

The Care Transition Coordinator (CTC) facilitates transitions from healthcare facilities to home health or hospice care. The role evaluates patient eligibility, coordinates care plans and ancillary services, and serves as a liaison among the agency, referral sources, healthcare providers, patients, and families. The CTC supports timely communication, documentation, and patient education while carrying out outreach and sales-administration activities that support market growth, financial stewardship, compliance, and patient satisfaction. The position works with assigned locations to meet production and Medicare-certified admission targets, grow market share, and coordinate accepted patient transitions. It also supports communication and coordination when existing home health patients transfer to a facility and, when applicable, resume care after discharge.

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.
Manage sales and marketing expenses with attention to 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 in accordance with Right of Choice guidelines.
Meet with patients face-to-face to explain agency services 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.
Complete Care Transition Coordinator encounter documentation in Home Care Home Base.
After acceptance, coordinate transfer orders and ancillary services, such as durable medical equipment and infusion services.
Educate patients about home care or hospice orders and related services, post-discharge physician appointments, prescriptions, medication regimens, pharmacy use, and medication delivery methods.
Ensure needs identified by referral sources are documented and addressed by the agency after acceptance.
Collaborate with the Executive Director and Clinical Director to align team efforts with referral-source and patient needs and expectations and promote growth.
Perform sales-administration duties, including BOA expense entry and policy compliance, payroll timesheet submission, weekly 3LS meeting participation, PTO requests, and attendance at required sales calls and company-provided in-services.
Maintain timely communication by phone and email.
Act 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 patients transfer from home health to a facility, and coordinate resumption of care before discharge when applicable orders are obtained.
Provide the case management team with follow-up feedback on 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.