Patient Transition Specialist

Job Description

Job Description

Description:

The Patient Transition Specialist plays a critical role in supporting patients as they transition from skilled nursing facilities (SNFs) to appropriate post-discharge health services at home. This individual works onsite within SNFs to identify patient needs, collaborate with interdisciplinary care teams, and facilitate smooth transitions back to the patient’s home that best supports recovery, safety, and continuity of care.

This role is ideal for a self-motivated professional with experience in case management, care coordination, or social work who is comfortable working independently in the field and building trusted relationships with facility staff, patients, and families.

Key Responsibilities

• Establish a consistent presence within assigned skilled nursing facilities to support post-discharge planning and care transitions
• Identify patients who may benefit from post-acute health services through collaboration with nursing, social services, and discharge planning teams
• Educate patients and families on available care options and support informed decision-making for post-discharge services
• Coordinate referrals and facilitate timely transitions to appropriate post-acute providers
• Serve as a liaison between SNF staff and post-acute care partners to ensure clear communication and continuity of care
• Document patient interactions, referrals, and outcomes in accordance with organizational and regulatory standards
• Build and maintain strong professional relationships within facilities through reliability, responsiveness, and ethical conduct
• Travel independently between assigned facilities within the designated territory

• Bachelor’s degree required; Master’s degree (MSW, MHA, or related field) preferred
• Background in case management, care coordination, social work, patient advocacy, or related healthcare roles
• Clinical licensure not required
• Strong understanding of care transitions, discharge planning processes, and patient support needs
• Excellent interpersonal, communication, and organizational skills
• Ability to work autonomously, manage time effectively, and prioritize in a dynamic environment
• Comfortable engaging with patients, families, and multidisciplinary healthcare teams

Travel & Work Environment

• Position requires regular local travel to skilled nursing facilities
• Must be willing and able to travel up to 1.5 hours driving distance within assigned territory
• Field-based role with minimal direct supervision

Key Attributes for Success

• Self-starter with strong initiative and follow-through
• Professional, compassionate, and patient-centered approach
• Adaptable and comfortable working across diverse facility environments
• Relationship-oriented with a collaborative mindset