Transitional Care Coordinator - CarDon Corporate

Cardon & Associates•Indianapolis, IN

About The Position

The Transitional Care Coordinator plays an integral role in supporting CarDon’s Transitional Care Program and ensuring coordinated transitions for residents across the continuum of care. The role works collaboratively with the Transitional Care Clinical Manager, community Social Services teams, interdisciplinary team members, hospital partners, home health agencies, and other post-acute partners to support effective transitions, reduce discharge barriers, and maintain continuity of care after residents transition home. The Coordinator and Transitional Care Clinical Manager coordinate program responsibilities and workflows, each bringing a different focus to the program. The Coordinator supports day-to-day program coordination across participating CarDon communities, assists with referral management and transition services, and maintains communication with internal and external partners. The role also supports residents after discharge by following up, coordinating responses to needs or concerns, connecting residents with resources and care-team members, and helping maintain continuity between the resident, CarDon community, and post-discharge partners. The Coordinator serves as a point of contact when residents need to return to a facility to avoid rehospitalization. The position supports community Social Services teams through education and reinforcement of program processes, referral workflows, and discharge coordination. It uses MatrixCare and electronic care coordination platforms such as Olio and Watershed for communication, referrals, documentation, and workflow follow-up. The Coordinator partners with community leadership and care teams, participates in program meetings and initiatives, identifies trends and opportunities for improvement, and supports consistency as the program expands across CarDon communities. The ideal candidate is organized, collaborative, relationship-focused, and passionate about helping residents transition successfully through the healthcare continuum. The role involves working across multiple CarDon communities and with a variety of internal and external partners.

Requirements

Strong communication, organization, and relationship-building skills.
Ability to collaborate effectively with interdisciplinary teams and external healthcare partners.
Comfort using electronic health records and technology-based care coordination platforms.
Ability to manage multiple priorities and follow through on time-sensitive needs.
Ability to review data and trending to initiate process improvement.

Nice To Haves

Background in social services, healthcare, care coordination, case management, discharge planning, or a related field.
Experience in skilled nursing, long-term care, hospital, home health, hospice, or other post-acute healthcare settings.
Understanding of discharge planning, community resources, and transitions of care.
Understanding of ACOs and value-based care programs.

Responsibilities

Support day-to-day coordination of the Transitional Care Program across participating CarDon communities.
Review and assist with management of Transitional Care referrals and ensure appropriate follow-through.
Assist with coordinating services and resources needed for successful transitions from the community to home.
Maintain communication with internal and external partners throughout transitions and serve as a post-discharge point of contact for home health, hospice, and post-acute ACO partners.
Support communication and follow-up with residents after discharge.
Coordinate responses to post-discharge needs, barriers, and concerns, and help connect residents with appropriate resources and care-team members.
Communicate identified concerns to appropriate CarDon team members, providers, home health agencies, and other care partners to promote timely intervention.
Help maintain continuity between residents, CarDon communities, and post-discharge care partners.
Serve as a point of contact when residents need to return to a facility to avoid rehospitalization.
Provide resources and support to community Social Services teams regarding Transitional Care Program processes and expectations.
Assist with education and reinforcement of Transitional Care workflows, referral processes, and discharge coordination.
Collaborate with Social Services teams to identify opportunities to strengthen discharge planning and transition-of-care processes.
Promote consistent communication and coordination across participating communities.
Use MatrixCare and electronic care coordination platforms such as Olio and Watershed to support communication, referrals, and transitional care workflows.
Monitor relevant platform activity and assist with timely follow-up and communication.
Maintain accurate and timely documentation of Transitional Care activities.
Help ensure appropriate visibility and communication among CarDon communities and external care partners.
Work collaboratively with the Transitional Care Clinical Manager to coordinate duties, responsibilities, workflows, and program priorities.
Partner with community leadership, nursing, Social Services, therapy, providers, home health agencies, and other care partners to support successful transitions.
Participate in Transitional Care meetings, education, and program initiatives.
Assist with identifying trends, barriers, and opportunities for improvement within the Transitional Care Program.
Support program growth and consistency as Transitional Care expands across CarDon communities.