Care Coordinator I, Care Transitions

Role Overview Avail Health is launching a hospital-based Care Transitions Program supporting Medicare-age patients with complex medical, behavioral health, and social needs following hospital discharge. The Care Coordinator I is the operational engine of that program—managing enrollment, scheduling, communication workflows, and the day-to-day logistics that keep the interdisciplinary team running. You’ll work onsite at the hospital alongside the Senior RN Manager, serving as one of the faces of Avail Health to hospital staff, patients, and caregivers. You’re not in a back‑office role— you’re a visible, trusted partner in the discharge and transition process. This is a ground‑floor opportunity. Early team members will help shape workflows, surface gaps, and build a program designed to scale. What You'll Own Enrollment and intake logistics from referral through successful program onboarding Provider scheduling and TCM visit coordination across the patient panel Day‑to‑day communication workflows: inbound calls, messages, faxes, and referral routing What You'll Do Support hospital‑based patient identification, referral intake, consent collection, and enrollment paperwork Coordinate post‑discharge appointments, telehealth and mobile visits, and provider schedules aligned to patient risk tier and program timelines Serve as a liaison between hospital staff, patients, caregivers, and the Avail Health care team — managing inbound/outbound calls, faxes, portal messages, and referral routing Prepare patients and caregivers for post‑discharge follow‑up and telehealth visit workflows; troubleshoot access and logistics proactively Support daily huddles and operational readiness activities with the interdisciplinary team Document interactions, scheduling updates, and coordination milestones in the EMR; support tracking of referral status and enrollment progression Escalate clinical concerns, discharge barriers, or urgent coordination issues to the Senior RN Manager promptly Contribute frontline feedback to identify workflow gaps and support process improvement as the program scales What Success Looks Like Inbound calls, messages, and faxes addressed promptly with clear resolution and minimal escalation Referrals, follow‑ups, and scheduling completed accurately and without gaps across the patient panel Responsive, collaborative relationships maintained with hospital teams to support efficient discharge coordination Provider schedules well‑managed, balancing patient access, clinical timelines, and operational efficiency EHR documentation timely, accurate, and meeting organizational standards Workflow gaps identified early and surfaced to leadership with constructive solutions What You'll Bring Required: High school diploma or GED required; associate degree or healthcare-related education strongly preferred 2+ years of experience in care coordination, medical or behavioral health practice, health insurance care management, patient access, or hospital operations Strong organizational skills with ability to manage concurrent workflows, frequent interruptions, and shifting priorities in a high-volume environment Excellent communication and interpersonal skills; strong customer‑service orientation with patients, caregivers, and clinical staff Comfort navigating multiple technology platforms simultaneously (EMR, scheduling, telehealth, communication tools) At ease in a startup‑style environment with evolving workflows and rapid growth Preferred: Experience in care management, population health, transitional care, or post‑acute settings Experience supporting patients with complex behavioral health, cognitive, substance use, or psychosocial needs Background in telehealth, mobile care, or home health operations Strong fit for candidates with combined clinical support and healthcare operations experience — e.g., home health or post‑acute LPNs with scheduling, referral coordination, or practice operations backgrounds Schedule and Work Style Work Type: Fully in‑person, hospital‑based, Rockville, MD Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET Travel: Daily on‑site presence required; must reside within commuting distance of Rockville, MD Autonomy: High operational ownership within a close‑knit team; direct daily partnership with the Senior RN Manager Compensation and Perks Salary Range: $52,000 – $68,000 annually, commensurate with experience Key Benefits: Medical coverage: DPC model + high‑deductible health plan; 100% of employee medical premiums covered Dental and vision insurance HSA with employer contributions | Company‑paid life and disability insurance 401(k) with 2% employer match 15 days PTO (accrued per pay period, increasing with tenure) | 8 + 1 floating holidays Mileage reimbursement: $0.725/mile for travel exceeding 30 miles/day (up to $200/day) All devices and technology provided #J-18808-Ljbffr Vail Health