Transitions Coordinator

Job Description

Job Description

Description

Schedule: Full time exempt, minimum 40 hours per week | Monday - Friday | 8:00 am - 4:30 pm
Department: Direct Care | Huron Valley PACE | Ypsilanti, MI

What You'll Do In This Role:
The Transitions Coordinator is a vital advocate for participants, ensuring every transition in care is smooth, safe, and seamless. Working closely with hospitals, rehabilitation centers, long-term care facilities, participants, families, and the Interdisciplinary Team (IDT), this role coordinates every step of the care journey to promote exceptional outcomes. From admissions and discharges to ongoing care transitions, the Transitions Coordinator champions continuity of care, proactively addresses participant needs, and helps eliminate gaps in services.
Key Responsibilities

Care Transition Coordination

• Coordinates participant care as they move between hospitals, nursing facilities, rehabilitation centers, and home.
• Shares important participant information with healthcare providers and facilities to ensure smooth transitions and continuity of care.
• Works with the Interdisciplinary Team (IDT), physicians, and facility staff to plan safe and effective discharges.

Participant Care and Support

• Visits participants in hospitals, nursing facilities, and homes to assess needs and provide support.
• Participates in hospital and nursing facility rounds to monitor participant health and progress.
• Monitors services provided in contracted facilities to ensure participants receive quality care.

Team Collaboration and Communication

• Maintains regular communication with hospitals, nursing facilities, healthcare providers, and the IDT regarding participant care.
• Shares updates on participant status and discharge plans with team members.

Quality and Compliance

• Reviews services and healthcare utilization to ensure participants receive appropriate care.
• Participates in quality improvement activities related to care transitions and participant outcomes.
• Maintains current knowledge of healthcare regulations, processes, and best practices.

Documentation and Record keeping

• Accurately documents participant care and coordination activities in the electronic medical record (EMR).
• Completes required transition of care notes in a timely manner.
• Complies with all organizational policies and applicable federal and state regulations.

Additional Responsibilities

• Travels regularly between PACE centers, participant homes, hospitals, skilled nursing facilities, and other locations throughout the service area.
• Performs other duties and responsibilities as assigned within the scope of practice and role.

The above is a summary of the position, it in no way states or implies that these are the only duties this position will be required to perform. If selected for the position you will receive a full job description.

Skills, Knowledge & Expertise

• Bachelors Degree in Social Work or Nursing preferred.
• Minimum of 1 year experience working with the frail elderly population.
• Experience in case management, care coordination, hospital discharge planning, home health, skilled nursing, long-term care, or PACE strongly desired.
• Excellent verbal and written communication skills, with the ability to effectively collaborate with participants, families, healthcare providers, and community partners.
• Position requires the ability to lift and move objects weighting up to 35 pounds without assistance.
• Valid Michigan driver's license, reliable transportation, and proof of automobile insurance.
• CPR certification or willing to obtain within 6 months of employment

Job Benefits

• Generous 6 weeks of Flexible time off per year —plus paid holidays on top of that.
• Competitive Benefits for Full-Time Team Members – Enjoy Medical, Vision & Dental Insurance starting on the 1st of the month after 30 days of hire.
• Retirement Savings Plan – Secure your future with employer contributions.
• Daily Pay –Instantly transfer your daily earnings. 
• Team Member Referral Bonus Program – Earn $500 when you bring great people to our team!
• Career Growth & Development – Advance your career with tuition assistance and school scholarships up to $3,000 per semester.
• Wellness Program & Reimbursemen t – Prioritize your health and well-being, reimbursed 120 a year!
• Mileage Reimbursement – Offered for work-related travel.

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