Care Transitions Coordinator
About The Position
As a Part-Time Care Transitions Health Coach, you will play a pivotal role in improving the health and well-being of residents across our county by helping patients and caregivers successfully navigate one of the most vulnerable moments in healthcare, the transition from hospital to home. In this role, you won’t just provide support; you will empower individuals with the knowledge, confidence, and tools they need to take control of their recovery and maintain their independence. If you are passionate about empowering others, advancing health equity, and creating lasting community impact, this role provides an opportunity to turn that passion into measurable change. The Part-time Care Transitions Health Coach works directly with patients through telephonic hospital outreach, post-discharge home visits, and follow-up phone calls. Through education and personalized support, the coach helps patients understand their medications, navigate follow-up care appointments, recognize warning signs or symptoms, and develop self-management strategies that promote long-term wellness and independence. This role emphasizes patient-centered care, collaboration with healthcare providers, and fostering self-advocacy to ensure successful recovery outcomes and improved quality of life.
Requirements
- High school diploma or G.E.D.
- 4 years of experience with older adults having complex care needs within the hospital system, case management, and service coordination.
- Experience entering, maintaining, and retrieving client information in electronic database systems.
- Must pass criminal background check pursuant to VA Code Ann. 19-392-92 (2010) and the Older Americans Act of 1965 as amended in Section 701.
- Must pass DMV Record check
- Must possess a valid driver's license
- Mandated reporter of elder abuse
- Must have a physical and TB and be cleared for employment
- CPR/First Aid/AED
- Mandated contracted systems training
Nice To Haves
- Bachelor's degree or higher in Behavioral Sciences, Human Services, Social Work, Gerontology, Education, Communications, Public Administration or related
- 5 years’ experience in working with older adults with disabilities
- Thorough knowledge of community resources and programs, to include health information privacy and benefited programs
- Well-organized person who can manage multiple priorities while meeting required deadlines and time-sensitive schedule
- Experience with researching and identifying community resources for clients, specifically those related to older adults and caregivers
- Experience building trust with clients to gather sensitive or complex information
- Bilingual Speaker - (English/Spanish) is a plus, but not required of applicant
Responsibilities
- Telephonic hospital outreach
- Post-discharge home visits
- Follow-up phone calls
- Educate patients on understanding their medications
- Assist patients in navigating follow-up care appointments
- Help patients recognize warning signs or symptoms
- Develop self-management strategies that promote long-term wellness and independence
- Provide patient-centered care
- Collaborate with healthcare providers
- Foster self-advocacy to ensure successful recovery outcomes and improved quality of life
Benefits
- 401a and 457 retirement savings and investment plans
- Paid Annual Leave
- Paid Personal Leave
- Paid Sick Leave
- Paid Holidays
- Optional Group Medical, Dental, & Vision Plans
- An Employee Assistance Program (EAP)
- Career Development Opportunities
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What This Job Offers
Job Type
Part-time
Career Level
Mid Level
Education Level
High school or GED
