Care Transition Coordinator

Job Description

Job Description

Overview

The Care Transition Coordinator (CTC) plays a pivotal role in facilitating seamless transitions for patients from healthcare facilities to home health or hospice care. This position is responsible for evaluating patient eligibility, coordinating care plans, and ensuring all services—including ancillary needs such as DME and infusion—are arranged in alignment with agency protocols and patient needs. The CTC serves as a liaison between the agency, referral sources, and healthcare providers, ensuring timely communication, documentation, and patient education. By executing strategic outreach plans and managing sales-related administrative functions, the CTC supports market growth, maintains compliance with financial stewardship, and enhances patient satisfaction through personalized, informed care transitions.

• Current and active licensure in the state of practice as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker (SW), or Physical Therapist (PT) is required.
• Respiratory Therapist (RT) certification and/or completion of a technical clinical program demonstrating strong clinical knowledge is preferred.

Office Location: Savannah, GA
Coverage area:   Savannah

Schedule: Full-Time

Responsibilities

• Achieve monthly personal production goals and Medicare-certified (MC) admission targets for assigned locations. Manage sales and marketing expenses to ensure financial stewardship and return on
investment.
• Implement weekly, monthly, and quarterly strategies to increase market share within assigned facilities.
• Evaluate patients and physician orders for home care eligibility in accordance with Right of Choice guidelines.
• Conduct face-to-face patient transitions to provide agency education and identify the primary care physician responsible for the plan of care.
• Present identified patient needs to the Executive Director to obtain branch approval and acceptance. Complete Care Transition Coordinator (CTC) encounter documentation in Home Care Home Base.
• Upon patient acceptance, coordinate transfer orders and ancillary services (e.g., DME, infusion). Educate patients on home care or hospice orders and related services received from the referral source.
• Ensure all patient needs identified by the referral source are documented and addressed by the agency upon acceptance.
• Collaborate with the Executive Director and Clinical Director to promote growth by aligning team efforts with the needs and expectations of referral sources and patients.

• Perform sales administration duties including BOA expense entry, adherence to BOA policies and procedures, payroll timesheet submission, participation in weekly 3LS meetings, submission of PTO
requests, and attendance at required sales calls and company-provided in-services. Maintain timely communication via phone and email.
• Educate patients on the importance of post-discharge physician appointments, obtaining necessary prescriptions prior to discharge, and understanding medication regimens, pharmacy use, and delivery
methods.
• Act as liaison between the agency and healthcare providers for newly referred patients and existing patients transferred to hospitals from home health services.
• Notify discharge planning of active patients transferred from home health to a facility. Coordinate resumption of care with patients prior to discharge when applicable orders are obtained.
• Provide follow-up feedback to the case management team on readmission status and non-admitdecisions based on agency-provided information.
• Maintain patient confidentiality in accordance with applicable laws and agency policies.
• Demonstrate knowledge of agency services, competitive advantages, specialty programs, and Medicare guidelines. Educate medical professionals using appropriate tools and literature.

Qualifications

• Required: Minimum of one (1) year of experience in home health or hospital-based case management.
• Preferred: One (1) to three (3) years of experience in medical marketing or healthcare business development.
• Current and active licensure in the state of practice as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker (SW), or Physical Therapist (PT) is required.
• Respiratory Therapist (RT) certification and/or completion of a technical clinical program demonstrating strong clinical knowledge is preferred.
• Must possess a valid driver’s license, reliable transportation, and current auto insurance.
• Demonstrated understanding of home health eligibility criteria and Medicare/insurance coverage guidelines is required.