Care Transitions Coordinator

Independent Living Systems • Lehigh Acres, FL

1d

About The Position

The Care Transitions Coordinator manages and coordinates member transitions between care settings, primarily supporting transitions from nursing facilities to community-based settings and, when appropriate, preventing avoidable transitions from the community to nursing facility placement. The role develops, implements, and coordinates individualized transition plans, collaborates with multidisciplinary teams, and addresses barriers to safe and successful transitions. Working with Care Managers, members, families, providers, and community resources, the Coordinator supports health outcomes, continuity of care, member safety and satisfaction, and adherence to care plans while helping reduce avoidable readmissions and institutional placements.

Independent Living Systems (ILS), together with its affiliated health plans Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for vulnerable populations. The Coordinator also demonstrates commitment to the organization’s mission and ILS Experience Standards of Excellence.

Requirements

• At least two years of relevant experience, with the listed qualifications.
• A bachelor’s degree in social work, sociology, psychology, gerontology, or a related social services field; or a bachelor’s degree in another field; or an RN license to practice in Florida; or an LPN license to practice in Florida with at least four years licensed. 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 ALF or 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.
• Collaborate with Care Managers to monitor member progress after discharge or transition and promptly 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.
• Identify and resolve transition barriers, 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
• Career Level: Mid Level