Transitional Care Coordinator - Onsite in Lee County, FL

The Transitional Care Coordinator is responsible for coordinating care for patients across the continuum to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. The scope of this job includes utilizing high level communication skills to assess and identify problems and outcomes, assisting patients with identifying and overcoming barriers, and evaluating the results.

*** This role will be working onsite in facilities based out of Lee County, Florida. ***

We invite you to apply today and join us in shaping the future of healthcare!

Key Responsibilities:

• Cultivate and maintain professional relationships with clients, patients, and stakeholders by providing sensitive and respectful care in line with diversity standards and human dignity.
• Conduct holistic assessments, prioritize patients based on need, and develop, implement, and revise care plans in collaboration with patients, families, and the healthcare team.
• Partner with healthcare providers, including physicians and hospital staff, to identify at-risk patients, reduce readmission risks, and facilitate smooth transitions across the healthcare continuum.
• Coordinate and educate program expectations with providers, payers, and families to ensure appropriate referrals and optimized clinical outcomes.
• Advocate for patient needs through effective communication and service coordination and promote patient self-management and wellness by empowering patients and families to make informed choices and build supportive care systems.
• Maintain accurate documentation, stay current on healthcare regulations and practices, and participate in team meetings and orientation activities to promote collaboration and continuous improvement.
• Perform other job duties as assigned.

Required Qualifications:

• Bachelor's degree from an accredited school of nursing and/or Allied Health program, and currently licensed in the state of employment
• At least 2-4 years' experience in field and/or direct patient care
• Valid driver's license
• Experience working with and/or good knowledge of federal, state, and local laws and regulatory guidelines governing home health and hospice operations.
• Experience in acute/ACO/post-acute care facility care coordination, discharge planning, social services, disease management, population health, home health, and/or post-acute care facilities

Preferred Requirements:

• Strong understanding of customer and market dynamics, as well as transitional care best practices.
• Proficient with Health Care IT technologies
• Demonstrated computer literacy skills

Job Expectations:

• Willing to travel up to 70% based on business needs
• Willing to work additional or irregular hours as needed
• Must work in accordance with applicable security policies and procedures to safeguard company and client information
• Must be able to sit and view a computer screen for extended periods of time

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WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference.

WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace.

Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.

Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:

• Excellent medical, dental, and vision benefits
• Mental health benefits through TelaDoc
• Prescription drug coverage
• Generous paid time off, plus 13 paid holidays
• Paid parental leave
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year