Transitional Care Specialist - Fulltime

Lorian Health • San Diego, CA

13d • $95,000 - $105,000 • Hybrid

About The Position

The Transitional Care Specialist is a corporate-level clinical operations leader responsible for designing, implementing, and overseeing Lorian’s Transitional Care across all Home Health branches. This full-time role combines field-based clinical presence, including home visits and bedside visits in hospitals, skilled nursing facilities, and other care settings, with strategic oversight, performance monitoring, and cross-functional leadership to improve outcomes for clinically complex, high-risk patients and support timely transitions across the continuum of care.

Requirements

• Minimum of 1 year of experience in home health or hospice
• Current, active, and unrestricted clinical licensure in the State of California, as applicable to role requirements.
• Strong understanding of transitional care workflows, high-risk patient management, hospitalization reduction strategies, and hospice transitions.
• Advanced knowledge of home health clinical operations, interdisciplinary team coordination, and compliant documentation practices.
• Ability to analyze workflow performance, identify gaps, and implement improvements across diverse branch environments.
• Strong communication, facilitation, and relationship-building skills with the ability to influence teams across the organization.
• Proficiency with EMR and reporting systems, including HCHB and other tracking tools used to monitor patient status, hospitalizations, and branch performance.

Nice To Haves

• Bachelor’s degree in Nursing, Social Work, healthcare administration, or related field preferred.

Responsibilities

• Conduct home visits and bedside visits as needed to assess complex cases, support patient and family education, reinforce clinical planning, and model best practices for branch teams.
• Travel regularly to branch locations, patient homes, hospitals, skilled nursing facilities, and other care settings in support of the program’s clinical and operational goals.
• Maintain a visible field presence to evaluate workflow effectiveness, identify barriers, and coach teams in real time.
• Collaborate with MSWs, RNs, LVNs, therapists, hospice teams, and clinical managers to improve patient transitions and goals-of-care planning.
• Support regular MSW rounds or related psychosocial review structures for complex transitional care cases.
• Ensure all program-related actions, communication, and interventions are documented accurately and timely in HCHB or other designated systems to support compliance and audit readiness.
• Track and evaluate program outcomes such as hospitalization avoidance, post-discharge retention, and hospice referral activity.
• Ability to access patient homes, hospitals, branch offices, and other clinical environments as needed.
• Ability to use standard office and clinical technology for documentation, communication, and reporting.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level