Care Transitions Coordinator

Job Description

Job Description

We are seeking a Care Transitions Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Care Transitions Coordinator plays an essential role in managing and coordinating member transitions between different care settings. This role is primarily focused on transitions from nursing facilities to community-based settings and, when appropriate, preventing avoidable transitions from the community to nursing facility placement. The Care Transitions Coordinator is responsible for developing, implementing and coordinating individualized transition plans; collaborating with multidisciplinary teams; and addressing barriers that may impact successful and safe transitions. Working closely with Care Managers, members, families, providers and community resources, the Care Transitions Coordinator helps optimize health outcomes, promote continuity of care, and reduce avoidable readmissions or institutional placements. By managing the logistical and care coordination components of transitions, the Care Transitions Coordinator supports member safety, satisfaction, and adherence to care plans.

Minimum Qualifications:

• With the following qualifications, have a minimum of two (2) years of relevant experience:

• Bachelor’s degree in social work, sociology, psychology, gerontology, or related social services field.
• Bachelor's degree in a field other than social science.
• Registered Nurse (RN) licensed to practice in the state of Florida.

• Licensed Practical Nurse (LPN) with a minimum of four (4) years licensed to practice in the state of Florida.
• Relevant professional human service experience may substitute for the educational requirement on a year-for-year basis.
• Strong knowledge of healthcare systems, discharge planning, and community resources.
• Excellent communication and interpersonal skills to effectively collaborate with diverse stakeholders.
• Proficiency in electronic health records (EHR) and basic computer applications.

Preferred Qualifications:

• Master’s degree in social work, public health or related field.
• Certification in Case Management (CCM) or equivalent.
• Experience working with diverse populations in community-based or facility (ALF or SNF) settings.
• Familiarity with trauma-informed care or behavioral health interventions and supports.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Develop, implement and coordinate individualized transition plans in collaboration with care management teams, members, families and providers.
• Coordinate communication between hospitals, nursing facilities, assisted living facilities, primary care providers, specialists, and community resources to ensure safe, timely, and seamless transitions between care settings.
• Collaborate with the care managers to monitor member progress following discharge or transition promptly addressing complications, service gaps, or concerns to reduce avoidable readmissions and adverse outcomes.
• Arrange and confirm post-discharge services, equipment, medications, transportation, and follow-up appointments necessary to support successful transitions.
• Educate members and their families regarding discharge instructions, follow-up care, available resources, and self-management strategies to promote independence and adherence to care plans.
• Identify and resolve barriers to successful transitions, including access to services, housing, caregiver support, and provider coordination issues.
• Maintain accurate, complete and timely documentation of transition activities, outreach efforts, and outcomes in accordance with regulatory, contractual, and organizational requirements.
• Perform other duties as assigned.