LPN/MA Transitions of Care Coordinator- HS Primary Care Clinics

Description Job Title: Transitions of Care Coordinator (Primary Care) Position Summary The Transitions of Care Coordinator is responsible for ensuring safe, timely, and effective transitions of patients between healthcare settings, including hospital discharges, emergency department visits, and post-acute care. This role focuses on reducing readmissions, improving patient outcomes, and supporting continuity of care through patient outreach, care coordination, and collaboration with the primary care team. Key Responsibilities Coordinate care for patients transitioning from hospitals, skilled nursing facilities, or other care settings back to primary care Perform timely post-discharge outreach (e.g., within 24–72 hours) to assess patient needs, medication adherence, and follow-up care Schedule and confirm post-discharge appointments with primary care providers Conduct medication reconciliation in collaboration with providers and pharmacists Identify and address barriers to care, including transportation, social determinants of health, and access to medications Educate patients and caregivers on discharge instructions, treatment plans, and warning signs Collaborate with physicians, nurses, case managers, specialists, and community resources to ensure coordinated care Track and monitor high-risk patients to reduce hospital readmissions and emergency department utilization Maintain accurate and timely documentation in the electronic health record (EHR) Support quality improvement initiatives related to care transitions and population health Qualifications Education & Experience Minimum 2–3 years of experience in care coordination, or primary care setting Licensed Practical Nurse (LPN) OR Certified Medical Assistant (MA) required Active and unrestricted license/certification in Arkansas (as applicable) Skills & Competencies Strong understanding of care transitions, discharge planning, and chronic disease management Excellent communication and patient engagement skills Ability to work collaboratively in a multidisciplinary team Knowledge of community resources and social services Strong organizational skills and attention to detail Proficiency with EHR systems and care management tools Key Performance Indicators (KPIs) Timeliness of post-discharge patient contact Completion rate of follow-up visits within recommended timeframes Accuracy and completeness of documentation #J-18808-Ljbffr