Transitional Care Coordinator (LVN)
About The Position
About the Role Touchstone Health is seeking a compassionate and proactive Transitional Care Coordinator to support patients moving from skilled nursing to home-based care. Based in San Antonio, TX, this field-based role serves both our Home Health and Hospice divisions, helping ensure every patient receives the right care, at the right time, in the right setting. You’ll work closely with skilled nursing facilities, hospital discharge planners, and internal clinical teams to coordinate smooth, safe transitions — supporting both the clinical needs and emotional readiness of patients and families.
Requirements
- LVN license (active and in good standing in the state of Texas)
- Strong communication and organizational skills
- Empathy, patience, and professionalism in all interactions
- Ability to work independently and thrive in a mobile, field-based role
- Reliable transportation and valid driver’s license required
Nice To Haves
- Previous experience in transitional care, discharge planning, case coordination, or admissions preferred
- Familiarity with Medicare eligibility guidelines for home health and hospice is a plus
Responsibilities
- Serve as a liaison between SNFs, hospitals, and Touchstone clinical teams to facilitate timely transitions to home health or hospice care.
- Educate patients, families, and referral partners on service offerings, eligibility, and what to expect after discharge.
- Coordinate patient assessments, gather documentation, and ensure readiness for admission.
- Monitor and communicate status updates across teams using shared communication platforms.
- Identify and escalate any barriers to discharge or concerns regarding eligibility or safety.
- Participate in internal care conferences and collaborate across service lines.
- Travel daily between SNFs, hospitals, and patient homes within the San Antonio area.
Benefits
- Mileage reimbursement for all field-based travel
- A supportive, mission-aligned team environment
- Opportunities to make meaningful impact in both home health and hospice settings
- Ongoing training and connection with a larger interdisciplinary team
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
