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.

The Care Transitions Coordinator plays a critical role in ensuring seamless and effective transitions of patients between different care settings, such as from hospital to home or rehabilitation facilities. This position focuses on coordinating care plans, communicating with multidisciplinary teams, and addressing potential barriers to successful recovery and continuity of care. The coordinator works closely with members, families, and healthcare providers to optimize health outcomes and reduce readmission rates. By managing the logistics and clinical aspects of care transitions, this role supports patient safety, satisfaction, and adherence to treatment plans. Ultimately, the Care Transitions Coordinator contributes to improving overall healthcare quality and efficiency within the community served.

Minimum Qualifications:

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or a related field.
• Minimum of 2 years experience in care coordination, case management, or a clinical healthcare setting.
• 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 Nursing, Social Work, Healthcare Administration, or a related field.
• Minimum of 2 years experience in care coordination, case management, or a clinical healthcare setting.
• Experience working with Medicare, Medicaid, or other insurance programs related to care transitions.
• Familiarity with quality improvement initiatives and patient safety protocols.
• Training in motivational interviewing or patient education techniques.
• Bilingual abilities to support diverse patient populations.

Responsibilities:

• Develop and implement individualized care transition plans in collaboration with healthcare providers and members.
• Coordinate communication between hospitals, primary care providers, specialists, and community resources to ensure continuity of care.
• Monitor member progress post-discharge and address any complications or concerns promptly to prevent readmissions.
• Educate members and their families about medication management, follow-up appointments, and self-care strategies.
• Maintain accurate and timely documentation of care transition activities and outcomes in compliance with regulatory standards.