Transitions Specialist & Onboarding Liaison

Bluestem Communities Management•McPherson, KS

2d•Onsite

About The Position

Bluestem PACE is looking for a full-time Transition Specialist & Onboarding Liaison to join our team! This role serves as the central point of coordination for supporting participant transitions across care settings while onboarding new employees. This role facilitates effective communication, ensures seamless integration of new team members, and promotes continuity of care for participants by coordinating transitions between hospitals, skilled nursing facilities, home care, and the PACE center. The position works collaboratively with interdisciplinary team members, community partners, participants, caregivers, and leadership to ensure a positive onboarding experience and successful care transitions.

Requirements

Must be proficient with electronic medical records and Microsoft Office applications.
Must have thorough knowledge of medical terminology.

Nice To Haves

A minimum of two years of experience in healthcare coordination, case management, human resources, onboarding, customer service, or LPN.
Experience in PACE, long-term care, managed care, or healthcare transitions.
Experience coordinating multiple priorities and maintaining confidentiality.
Strong interpersonal and relationship-building skills.
Excellent written and verbal communication abilities.
Ability to manage multiple tasks and deadlines effectively.
Knowledge of healthcare systems, community resources, and care coordination principles.
Strong organizational and problem-solving skills.
Ability to work independently and as part of an interdisciplinary team.
Demonstrated commitment to customer service and participant-centered care.

Responsibilities

Initiate and manage Transition Work Plans for all participant transitions, including new enrollees, emergency room visits, hospitalizations, respite stays, and discharges to home.
Audit Transition Work Plans to ensure compliance and effectiveness, providing education, guidance, and follow-up with IDT members as needed.
Communicate with participants, caregivers, providers, and community partners to facilitate safe and timely transitions.
Review discharge plans and ensure follow-up services are arranged.
Monitor the EMR after transitions to identify barriers, gaps in care, or potential readmission risks.
Ensure required documentation is completed accurately and on time.
Educate participants and caregivers regarding care plans, follow-up appointments, medications, and available resources.
Track transition outcomes and identify opportunities to improve participant experience and quality outcomes.
Participate in quality improvement initiatives related to care coordination and transitions.
Coordinating home visits for transition coordination to discharging participant home from respite.
Serve as the primary contact for newly hired employees from offer to acceptance through completion of orientation.
Coordinate onboarding activities, orientation schedules, and department introductions.
Ensure completion of onboarding requirements, including training assignments, policy acknowledgments, and required documentation.
Communicate regularly with new hires to answer questions and provide support during the onboarding process.
Collaborate with Human Resources, department leaders, and educators to facilitate a smooth transition into assigned roles.
Monitor onboarding progress and follow up on outstanding requirements.
Coordinate welcome activities and promote employee engagement during orientation and onboarding.
Track onboarding metrics and identify opportunities for process improvement.
Assist with retention initiatives by conducting check-ins with new employees during their first 90 days.