Transitional Care Coordinator

Transitional Care Coordinator Registered Nurse (RN) or Medical Social Worker Position Summary The Transitional Care Coordinator is a key leader in coordinating safe, effective transitions of care for patients and their families. This position oversees the assessment, planning, coordination, implementation, and evaluation of transitional care services from pre-admission through discharge and transition back to the community or next level of care. Working closely with the Medical Director, providers, nursing, therapy, social services, case management, and other members of the healthcare team, the Transitional Care Coordinator helps ensure that patients receive the right services at the right time while reducing barriers to successful transitions. This position is well suited for an experienced Registered Nurse or Medical Social Worker with a strong background in case management, discharge planning, care coordination, utilization management, or post-acute care. Key Responsibilities Transitional Care Program Leadership Provides leadership for the Transitional Care Program in collaboration with the Medical Director, Director of Nursing and interdisciplinary care team. Coordinates program implementation, patient care, referral development, staff education, and quality improvement activities. Maintains knowledge of applicable Transitional Care Program processes, clinical guidelines, payer requirements, and CMS requirements. Serves as a resource to staff, providers, patients, and families regarding transitional care services. Provides education and orientation to employees regarding the Transitional Care Program. Coordinates and leads weekly interdisciplinary team rounds and utilization review meetings. Promotes effective communication and collaboration across disciplines and throughout the continuum of care. Patient & Family Care Coordination Coordinates care from referral and pre-admission through discharge and transition to the next level of care. Conducts or coordinates assessments to identify patient and family needs, barriers to discharge, available supports, and potential risks for readmission. Develops and coordinates individualized transition and discharge plans with patients, families, providers, and the interdisciplinary care team. Helps patients and families navigate healthcare services and available community resources. Provides discharge planning support for acute care patients as needed. Identifies potential barriers to successful transitions and works with the care team to address those barriers. Facilitates communication among patients, families, providers, referring facilities, and community partners. Advocates for patient-centered plans that reflect individual goals, needs, preferences, and available resources. Pre-Admission & Intake Coordination Reviews referrals and evaluates appropriateness for the Transitional Care Program. Works with providers and interdisciplinary team members to determine whether GCMC can safely and appropriately meet the patient's needs. Collaborates with discharge planners, case managers, social workers, and other referral partners at acute care hospitals. Coordinates required skilled nursing, therapy, or other services prior to admission. Ensures an appropriate payer source has been identified and collaborates with business office staff regarding coverage. Maintains working knowledge of Medicare and other payer requirements applicable to transitional and skilled care. Identifies risk factors for readmission and works with patients, families, and care team members to mitigate identified risks. Visits prospective patients in acute care settings during the referral/intake process when appropriate. Quality & Program Development Monitors Transitional Care Program quality measures and outcomes. Ensures required program and quality data are collected and reported. Participates in the development and implementation of improvement plans when opportunities are identified. Helps maintain program policies, procedures, clinical resources, and process guidelines. Evaluates opportunities to strengthen or expand transitional care services based on the needs of patients and the community. Participates in ongoing development of the Transitional Care Program. Referral & Community Relationships Develops and maintains strong working relationships with hospitals, discharge planners, case managers, social workers, providers, and other referral partners throughout the region. Participates in outreach and referral-development activities to increase awareness of GCMC Transitional Care Program. Travels to referring facilities periodically to build and maintain relationships and support effective patient transitions. Serves as a knowledgeable resource to referral partners regarding program services and admission criteria. Qualifications Applicants may qualify through either a nursing or medical social work background. Required One of the following: Current RN license with eligibility to practice in Montana; or Medical Social Worker who meets applicable education, credentialing, and/or licensure requirements for the position. Bachelor's degree in nursing, social work, or a closely related healthcare field. Appropriate combinations of education and experience may be considered consistent with applicable requirements. Relevant professional experience in healthcare, preferably involving care coordination, case management, discharge planning, utilization management, social services, post-acute care, or a related area. Demonstrated ability to coordinate complex patient needs across multiple healthcare disciplines and settings. Strong communication, relationship-building, organizational, and problem-solving skills. Ability to work effectively and independently within an interdisciplinary healthcare team. Ability to travel within the region. Valid driver's license, required vehicle insurance, and dependable transportation. Preferred Three or more years of experience in nursing, medical social work, case management, discharge planning, care coordination, or a related healthcare role. Experience with Medicare, skilled care, utilization management, or post-acute/transitional care. Experience working with rural healthcare systems and community resources. Experience developing relationships with referring hospitals, providers, and community partners. Healthcare outreach, referral development, or program-development experience. Discipline-Specific Responsibilities For an RN in this position: Provides clinical nursing support within the RN's scope of practice. Maintains licenses and certifications required by GCMC for the nursing responsibilities assigned to the position. May provide clinical backup to hospital departments when appropriately trained, credentialed, and assigned. For a Medical Social Worker in this position: Provides psychosocial assessment, resource coordination, patient and family advocacy, and discharge-planning services within the individual's professional scope. Connects patients and families with appropriate community, financial, behavioral health, social support, and post-discharge resources. Collaborates with nursing and providers when a patient's needs require clinical assessment or nursing intervention.