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Sutter HealthNew
Overview
Coordinates and implements transition of care and discharge plans for ambulatory patients. Ensures timely discharge through communication and teamwork between providers, patients, families, and external vendors.
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Compensation
$34 - $44 / HOUR
Posted
New
CVS HealthNew
Manage the transition of members from nursing facilities back into the community by developing member-centered care plans and coordinating safe discharges. Conduct face-to-face follow-up assessments and collaborate with interdisciplinary teams to reduce hospital readmissions.
$32 - $69 / HOUR
The Transition of Care Associate coordinates care for members experiencing significant health changes to ensure seamless transitions between care settings. Responsibilities include conducting post-discharge questionnaires, managing medications, and collaborating with interdisciplinary teams to reduce hospital readmissions.
$21 - $49 / HOUR
Community Health Centers of the Rutland Region
The Clinical Community Health Worker coordinates care for patients discharged from inpatient or emergency settings by scheduling follow-ups and facilitating communication. They also provide patient education, perform outreach, and assist with social determinants of health needs to support wellness goals.
$19 - $33 / HOUR
15 days ago
University of Maryland Medical System
The coordinator identifies and enrolls heart failure patients into the Virtual Bridge Clinic to support their transition across care settings. They provide outreach, education, and coordination of medical and social resources to improve patient health outcomes.
Salary not listed
20 days ago
Cedars-Sinai
Oversee daily organization and supervision of transitions of care medication management activities. Provide clinical and drug distribution services to ensure safe patient transitions.
$68 - $108 / HOUR
28 days ago
Molina Healthcare
Facilitates the transition of members from hospital admission to other settings to reduce readmissions through a 30-day oversight program. Coordinates care by collaborating with providers, conducting visits, and educating members on the Transition of Care Pillars.
1 month ago
Greater Lawrence Family Health Center
The coordinator manages the transition of high-risk behavioral health patients from inpatient or emergency settings back into the community. This includes conducting timely outreach, coordinating with multidisciplinary teams, and addressing social barriers to care to reduce avoidable hospital utilization.
$78,395 - $91,457 / YEAR
Facilitates the transition of members from hospital admission to other settings to reduce readmissions. Provides education on medication management, follow-up care, and functional needs while coordinating with interdisciplinary care teams.
$28 - $54 / HOUR
The Transition of Care Coach provides support for care transition activities, ensuring safe and appropriate transitions for members from hospital discharge to other settings. The role involves collaborating with various healthcare professionals and conducting assessments to reduce member readmissions.
UChicago Medicine
The Patient Navigation Coordinator supports hospitalist clinicians by facilitating timely patient care and enhancing communication between families, providers, and external organizations. The role also focuses on improving the transition of care process and optimizing administrative efficiency within the hospital medicine section.
$62,200 - $72,600 / YEAR
Hackensack Meridian Health
The Transitions of Care Doula provides continuous physical, emotional, and informational support to birthing individuals throughout the prenatal, labor, and postpartum periods. Additionally, the role involves coordinating post-discharge care plans and facilitating communication between families and the clinical healthcare team.
$27 / HOUR
The Transition of Care Coach facilitates care transition processes for members moving from hospital settings to home or other facilities to reduce readmissions. They conduct face-to-face visits, coordinate with interdisciplinary teams, and educate members on health management and care pillars.
$26 - $59 / HOUR
HonorHealth
The Case Manager guides care coordination for high-risk acute care patients and facilitates safe discharge plans for those with complex needs. They also analyze medical records to ensure compliance with regulatory standards and insurance guidelines while collaborating with the healthcare team.
Regal Medical Group
The Case Manager RN assesses, develops, and implements care plans for high-risk members to ensure appropriate care and prevent hospital readmissions. They act as a liaison between physicians, members, and healthcare providers while coordinating transitions of care and community resources.
$45 - $50 / HOUR
2 months ago
SUNY Downstate Health Sciences University
The Social Worker 2 will provide inpatient and outpatient coverage, focusing on transition of care and post-acute follow-up for patients. They will work with multidisciplinary teams to assess and address psychosocial needs, ensuring effective discharge planning and resource coordination.
Appalachian Regional Healthcare, Inc.
The Registered Nurse is responsible for completing comprehensive patient assessments, formulating and adjusting the plan of care using critical thinking, and providing physical and psychological support to patients and families. This role also involves supervising team members, administering treatments, and ensuring a safe environment.
The Registered Nurse completes patient assessments, formulates and adjusts the plan of care using critical thinking, and provides physical and psychological support to patients and families. Responsibilities also include administering prescribed treatments, supervising team members, and participating in performance improvement initiatives.
Baptist Health
The Transition of Care Nurse manages the inception of the transition of care document and validates received data, which involves developing a comprehensible transition plan into a physician practice or higher level of care. This role ensures all providers operate with the same information for continuity of care and validates data through direct patient phone conversations after appointments are scheduled.
The Advanced Practice Nurse (APN) or Physician Assistant utilizes a patient-centered coordinated care model, performing comprehensive assessments, ordering and interpreting diagnostic studies, and managing general medical and surgical conditions for inpatient neurology patients. Responsibilities also include prescribing medication safely, evaluating transition of care planning, and serving as a clinical resource and advocate for patients and families.
$72 / HOUR
