Job Title: Transitions of Care Coordinator (Primary Care)
Position Summary
The Transitions of Care Coordinator is responsible for ensuring safe, timely, and effective transitions of patients between healthcare settings, including hospital discharges, emergency department visits, and post-acute care. This role focuses on reducing readmissions, improving patient outcomes, and supporting continuity of care through patient outreach, care coordination, and collaboration with the primary care team.
Key Responsibilities
Coordinate care for patients transitioning from hospitals, skilled nursing facilities, or other care settings back to primary care
Perform timely post-discharge outreach (e.g., within 24–72 hours) to assess patient needs, medication adherence, and follow-up care
Schedule and confirm post-discharge appointments with primary care providers
Conduct medication reconciliation in collaboration with providers and pharmacists
Identify and address barriers to care, including transportation, social determinants of health, and access to medications
Educate patients and caregivers on discharge instructions, treatment plans, and warning signs
Collaborate with physicians, nurses, case managers, specialists, and community resources to ensure coordinated care
Track and monitor high-risk patients to reduce hospital readmissions and emergency department utilization
Maintain accurate and timely documentation in the electronic health record (EHR)
Support quality improvement initiatives related to care transitions and population health
Qualifications
Education & Experience
Minimum 2–3 years of experience in care coordination, case management, or primary care setting
Licensed Practical Nurse (LPN) required
Active and unrestricted license/certification in Arkansas (as applicable)
Skills & Competencies
Strong understanding of care transitions, discharge planning, and chronic disease management
Excellent communication and patient engagement skills
Ability to work collaboratively in a multidisciplinary team
Knowledge of community resources and social services
Strong organizational skills and attention to detail
Proficiency with EHR systems and care management tools
Key Performance Indicators (KPIs)
Timeliness of post-discharge patient contact
Completion rate of follow-up visits within recommended timeframes
Accuracy and completeness of documentation
