Care Transition Coordinator

Adoration Health•Wheeling, WV

27d

About The Position

The Care Transition Coordinator (CTC) facilitates transitions for patients 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 serves as a liaison among the agency, referral sources, healthcare providers, and patients, supporting timely communication, documentation, and patient education. The position also carries out outreach strategies and sales-administration duties to support market growth, financial stewardship, compliance, and patient satisfaction.

Requirements

At least one year of experience in home health or hospital-based case management.
Current and 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 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 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.
After patient acceptance, coordinate transfer orders and ancillary services such as DME and infusion, and educate patients about home care or hospice orders and related services.
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, following BOA policies and procedures, submitting payroll timesheets and PTO requests, participating in weekly 3LS meetings, and attending 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, and understanding medication regimens, pharmacy use, and delivery methods.
Act as a 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 with patients 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.