Clinical Transitions Coordinator
Central Florida Inpatient Medicine•Cape Coral, FL
8d
About The Position
The Clinical Transitions Coordinator (CTC) proactively manages patient flow across the post-acute continuum to reduce avoidable utilization, optimize length of stay (LOS), ensure accurate attribution, and deliver safe, timely transitions of care. This role serves as the operational owner of post-acute transitions, partnering closely with Skilled Nursing Facilities (SNFs), MSOs, providers, and hospital case management. Candidates must be located in SW FL, w/in 30 mile radius of Cape Coral/Ft Myers area
Requirements
- 5 years of nursing experience
- Experience in case management, home health nursing, skilled nursing facility nursing.
- Current nursing license – Registered Nurse with a BSN preferred
- CPR/BLS certification
- Comprehensive nursing assessment, problem identification, and care plan development
- Implementation of clinical pathway knowledge
- Relationship building with patients, families, facility staff, providers, and MSO/ACO partners
- Documentation in EMR
- Proficient in MS Office, especially Outlook, Word, Excel, and PowerPoint
- Organized and resourceful self-starter
- Excellent written, oral, interpersonal, and communication skills
Nice To Haves
- Motivational interviewing experience preferred
- Managed care and Utilization Review experience is a plus
Responsibilities
- Own daily tracking of admissions, discharges, readmissions, and LOS
- Ensure Spectrum Medical Partners attribution prior to SNF admission
- Escalate missed attribution to leadership and hospital case management
- Identify all new SNF admissions daily
- Ensure provider visit scheduled within 24 hours
- Confirm assignment with SNF Admissions teams
- Monitor LOS daily and flag patients exceeding thresholds
- Identify barriers to discharge and drive Plan A / Plan B planning
- Partner with SNF, MSO, and Nurse Navigators on next‑level‑of‑care transitions
- Identify all readmissions in real time
- Complete root cause reviews
- Share learnings during IDT and align on prevention actions
- Participate onsite weekly at high‑volume SNFs
- Lead goal‑oriented IDT discussions
- Ensure follow‑through on agreed actions
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
