Care Transitions Coordinator

Independent Living Systems • Lehigh Acres, FL

4h

About The Position

Independent Living Systems (ILS), together with its affiliated health plans Florida Community Care and Florida Complete Care, is committed to promoting quality of life and maximizing independence for vulnerable populations.

The Care Transitions Coordinator manages and coordinates member transitions between care settings, primarily transitions from nursing facilities to community-based settings and, when appropriate, prevention of avoidable transitions from the community to nursing facilities. The role develops, implements, and coordinates individualized transition plans; collaborates with multidisciplinary teams; and addresses barriers to safe, successful transitions. Working with Care Managers, members, families, providers, and community resources, the coordinator supports health outcomes, continuity of care, and the reduction of avoidable readmissions and institutional placements. The role manages logistical and care coordination components of transitions to support member safety, satisfaction, and adherence to care plans.

Requirements

• At least two years of relevant experience, subject to the stated qualification pathways.
• A bachelor’s degree in social work, sociology, psychology, gerontology, or a related social services field; a bachelor’s degree in another field; or a Florida-licensed Registered Nurse (RN).
• A Florida-licensed Licensed Practical Nurse (LPN) with at least four years of licensure may qualify under the stated pathway.
• Relevant professional human service experience may substitute for the educational requirement on a year-for-year basis.
• Strong knowledge of healthcare systems, discharge planning, and community resources.
• Excellent communication and interpersonal skills to collaborate effectively with diverse stakeholders.
• Proficiency in electronic health records (EHR) and basic computer applications.

Nice To Haves

• Master’s degree in social work, public health, or a related field.
• Certification in Case Management (CCM) or equivalent.
• Experience working with diverse populations in community-based or facility settings, including assisted living facilities (ALF) or skilled nursing facilities (SNF).
• Familiarity with trauma-informed care or behavioral health interventions and supports.

Responsibilities

• Demonstrate commitment to the organization’s mission and model ILS Experience Standards of Excellence.
• Develop, implement, and coordinate individualized transition plans in collaboration with care management teams, members, families, and providers.
• Coordinate communication among hospitals, nursing facilities, assisted living facilities, primary care providers, specialists, and community resources to support safe, timely, and seamless transitions between care settings.
• Collaborate with Care Managers to promptly monitor member progress following discharge or transition and address complications, service gaps, or concerns to reduce avoidable readmissions and adverse outcomes.
• Arrange and confirm post-discharge services, equipment, medications, transportation, and follow-up appointments needed for successful transitions.
• Educate members and families about discharge instructions, follow-up care, available resources, and self-management strategies to promote independence and adherence to care plans.
• Identify and resolve barriers to successful transitions, including access to services, housing, caregiver support, and provider coordination issues.
• Maintain accurate, complete, and timely documentation of transition activities, outreach efforts, and outcomes in accordance with regulatory, contractual, and organizational requirements.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time