Transitional Care Coordinator – Home Health

As a Transitional Care Navigator at Addus Family company, you will support patients and families through care transitions from hospital or facility to home or community-based services. You will coordinate discharge plans, schedule follow-up appointments, and connect clients with Addus’ personal care, home health, or hospice services to promote safe, timely transitions and reduce readmissions. In this client-centered role, you’ll collaborate with interdisciplinary teams, educate patients on care plans and resources, and advocate for dignity, respect, and independence. Addus offers training, growth opportunities, and a compassionate culture focused on quality care. Coordinate safe transitions from hospital or facility to home or community-based care Develop and implement individualized transitional care plans Schedule and confirm follow-up medical appointments and services Educate patients and families on discharge instructions, medications, and resources Collaborate with physicians, nurses, social workers, and community providers Identify barriers to care (transportation, housing, support) and address or escalate Link patients with Addus home care, home health, or hospice services Monitor patient progress post-discharge and follow up to reduce readmissions Document assessments, plans, and outcomes in electronic health records Participate in quality improvement initiatives and care coordination meetings Care coordination Discharge planning Patient assessment and triage Knowledge of home health and community-based services Electronic health records (EHR) documentation Interdisciplinary team collaboration Motivational interviewing/patient education Healthcare regulations and compliance (HIPAA) Time management and caseload prioritization Data tracking and reporting for readmissions/quality metrics Medical Insurance Dental Insurance Vision Insurance Life Insurance 401k Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN) license preferred Certified Case Manager (CCM) preferred Care management or patient navigation training a plus CPR/BLS certification preferred