Care Transition Coordinator

Atlantic Shores Retirement Community•Virginia Beach, VA

3d•$21 - $27•Onsite

About The Position

The Care Transition Coordinator organizes and facilitates safe, timely resident transitions from Seaside Health Center under the direction of the Licensed Clinical Social Worker (LCSW). The role coordinates discharge arrangements, equipment, services, communications, and documentation in collaboration with residents, families, nursing, therapy, and medical providers. The coordinator supports resident-centered care and continuity of care by identifying resident needs and discharge goals, arranging services and follow-up, maintaining required records, and addressing barriers to discharge. The position is part time at Atlantic Shores Retirement Community in Virginia Beach, Virginia, with an hourly salary range of $21.28 to $26.61 based on experience. Atlantic Shores is an award-winning continuing care retirement community serving people ages 55 and up. Its mission is to promote active lifestyles in a welcoming community that ensures freedom, dignity, wellness, independence, and security for residents and staff.

Requirements

High school diploma or equivalent required.
Strong organizational and time management skills, including the ability to manage multiple priorities and resident transitions.
Effective verbal and written communication skills with residents, families, healthcare providers, and interdisciplinary team members.
Ability to maintain accurate documentation, protect confidential information, and ensure timely follow-through on assigned responsibilities.
Knowledge of resident-centered care practices, discharge planning, and transition coordination processes.
Strong customer service, problem-solving, and relationship-building skills.
Proficiency with electronic health records (EHRs), Microsoft Office, and other technology systems.
Knowledge of healthcare compliance requirements, including CMS standards and facility policies.

Nice To Haves

Associate degree in Social Work, Human Services, Healthcare Administration, Gerontology, Psychology, or a related field.
At least two years of experience in healthcare, senior living, skilled nursing, rehabilitation, resident services, care coordination, discharge planning support, or a related field.
Experience coordinating services, communicating with residents and families, and collaborating with interdisciplinary healthcare teams.
Familiarity with skilled nursing, post-acute care, long-term care, senior living, or continuing care retirement community (CCRC) environments.
Experience using electronic health records (EHRs), healthcare documentation systems (PointClickcare), Medicare notices, and Microsoft Office applications.
Equivalent combinations of education, training, and relevant experience may be considered.

Responsibilities

Complete admission social services assessments and identify resident needs, preferences, and discharge goals.
Coordinate discharge planning activities, communicate with residents and families, and help ensure timely transitions of care.
Arrange home health services, durable medical equipment, and follow-up appointments to support successful discharges.
Prepare and maintain discharge documentation, referrals, and care coordination records in accordance with regulatory requirements.
Schedule and participate in resident care conferences, collaborating with the interdisciplinary team to address concerns and support care plans.
Monitor discharge progress, identify barriers, and escalate concerns to ensure continuity of care and positive resident outcomes.
Maintain compliance with CMS regulations, HIPAA requirements, resident rights, and facility policies.
Support quality improvement efforts while delivering exceptional customer service and demonstrating Atlantic Shores' commitment to resident-centered care.

Benefits

1.5x holiday pay for hourly employees.
1.5x overtime pay for every hour worked over 40 hours per week.
Generous PTO beginning with a maximum of 104 hours annually for full-time employees.
Medical, dental, vision, life, and short- and long-term disability coverage.
Supplemental accident, cancer, and critical illness coverage.
Legal resources and identity theft protection.
Tuition reimbursement up to $5,250 annually for qualifying coursework.
401(k) with company match.
Educational partnership discounts at South University, ECPI, Regent University, St. Leo University, and Colorado Christian University.
Referral bonus for new employee referrals who join the team.
Star Employee Recognition Program, including monetary awards.
Employee Assistance Program (EAP).
Flexibility to choose health and welfare plans.