Care Transitions Coordinator

Independent Living Systems, LLC • Tampa, FL

7d

About The Position

The Care Transitions Coordinator manages and coordinates member transitions between care settings, primarily from nursing facilities to community-based settings, and helps prevent 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, 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 or institutional placements. The role also manages the logistical and care coordination aspects of transitions to support member safety, satisfaction, and adherence to care plans.

Requirements

• At least two years of relevant experience with the stated qualifying education or licensure.
• Bachelor’s degree in social work, sociology, psychology, gerontology, or a related social services field; alternatively, a bachelor’s degree in another field or a Florida-licensed RN.
• A Florida-licensed LPN with at least four years of licensure may qualify.
• 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 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 settings.
• 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 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 transitions.
• Collaborate with Care Managers to monitor member progress after discharge or transition and promptly address complications, service gaps, or concerns.
• Arrange and confirm post-discharge services, equipment, medications, transportation, and follow-up appointments.
• 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, and outcomes in accordance with regulatory, contractual, and organizational requirements.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time