Care Transition Coordinator

Adoration Health•Rome, GA

13d

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 such as durable medical equipment (DME) and infusion in accordance with agency protocols and patient needs. The CTC serves as a liaison among the agency, referral sources, healthcare providers, and patients, supporting timely communication, documentation, and patient education. The position also supports market growth through outreach strategies and sales-related administrative duties, while maintaining financial stewardship, compliance, and patient satisfaction. Adoration Health provides home-based services and support for patients, families, and caregivers.

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, 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, 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, and complete CTC encounter documentation in Home Care Home Base.
Coordinate transfer orders and ancillary services, including DME and infusion, after patient acceptance.
Educate patients on home care or hospice orders and services, post-discharge physician appointments, prescriptions, medication regimens, pharmacy use, and delivery methods.
Ensure patient needs identified by referral sources are documented and addressed upon agency acceptance.
Collaborate with the Executive Director and Clinical Director to support growth and align team efforts with referral-source and patient needs.
Complete sales administration duties, including BOA expense entry, payroll timesheet submission, PTO requests, participation in weekly 3LS meetings, 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 home health patients are transferred to a facility and coordinate resumption of care before discharge when applicable orders are obtained.
Provide follow-up feedback to the case management team on readmission status and non-admit decisions based on agency-provided information.
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.