Care Transition Specialist

Guardian Home Care of NH

About The Position

The Care Transition Specialist plays a critical role in ensuring seamless initiation of services for newly admitted clients by providing immediate coverage during the transition period prior to assignment of a permanent caregiver. This position supports timely admissions, continuity of care, and high-quality client experience by stabilizing new cases while permanent caregivers complete onboarding and orientation requirements. As the first caregiver assigned to a new client, the Care Transition Specialist establishes rapport with clients and families, implements the initial care plan, observes and reports client needs, and communicates relevant updates to the clinical and operations teams. The specialist serves as a key liaison during the early stage of service delivery, helping identify adjustments needed to promote long-term success and caregiver matching. The Care Transition Specialist also facilitates a structured and professional handoff to the permanent caregiver, ensuring continuity, clear communication, and a smooth transition of care. This role operates under the direction and supervision of the Clinical Director and the VP of Operations and directly supports agency growth, client retention, and service reliability by preventing delays in care initiation and reducing admission related service gaps.

Requirements

High School Diploma or GED
Successful completion of any required training programs that meet State and agency regulations.
Show evidence of fulfilling the State health requirements.
Valid drivers’ license
Must be 18 years or older
Successfully complete 12 in-services by December 1 of current year
6 Hours initial of Dementia Training and 4 hours yearly continued
Prior experience in home care is required
Knowledgeable in-home care rules and regulations
Be aware of and adhere to all HIPAA rules and regulations and must be an active participant in safety measures for ensuring confidentiality of information as it relates to clients and this agency
Good oral, written and reading communication skills. Have the ability to understand verbal and written instructions. Read and write documentation.
Resourcefulness, flexibility, and integrity. Ability to work independently. Ability to function in a team oriented environment
Ability to make meaningful observations and write brief and accurate reports when necessary

Nice To Haves

LNA certification is preferred but not required

Responsibilities

Review Plan of Care prior to first shift
Establish rapport with client and family
Maintain flexibility during onboarding period
Participate in transition planning
Provide structured handoff to permanent caregiver
Assist client with personal hygiene (bathing, shampooing, shaving, oral hygiene)
Assist with dressing, ambulation, toileting, and safe transfer techniques per Plan of Care
Prompt client with self-administered medications per care plan
Assist with physician-ordered treatments/therapies as approved and supervised by RN
Carry out assignments per the client’s care plan
Notify scheduling and Clinical Director if unable to complete assigned care
Plan and prepare nutritious meals or modified diets as prescribed
Assist with activities of daily living (ADLs) as directed
Perform routine housekeeping to maintain a safe and comfortable environment
Accompany client to authorized appointments (when approved by office)
Report changes in client condition or home situation immediately
Maintain accurate documentation through Mobile App
Follow EVV compliance procedures
Respect client cultural and religious practices
Maintain neat, clean, orderly appearance (Dress Code Policy)
Conduct oneself in a manner that promotes client safety
Perform additional duties as directed by Director of Client Services, Administrator, or designee
Provide client routine overview to permanent caregiver
Communicate client preferences and observations
Participate in overlap shift when possible