Care Transition Coordinator

Our take on this role

About this role

Coordinate resident discharges from Seaside Health Center under the direction of a licensed clinical social worker, arranging services, equipment, and follow-up appointments. This is a part-time role in Virginia Beach.

What could you bring from clinical work?

• Social workers: Assessing residents' psychosocial needs and discharge goals could help you complete admission social services assessments and identify discharge goals.
• Nurses: Your experience preparing patients for discharge may help you arrange home health services and follow-up appointments.
• OTs and PTs: Identifying equipment needs for discharge could help you arrange durable medical equipment for residents leaving Seaside Health Center.

Full job description from Atlantic Shores Retirement Community

Job Details: Job Location: Atlantic Shores Retirement Community - Virginia Beach, VA, Position Type: Part Time, Salary Range: $21.28 - $26.61Hourly, Make a meaningful impact by helping residents and families navigate successful transitions of care. As a Care Transition Coordinator, you will work closely with an interdisciplinary team to coordinate discharge plans, connect residents with needed resources, and support safe, seamless transitions from Seaside Health Center.

Earn a competitive hourly wage based on years of experience.

Additional compensation includes:

Hourly employees:

1.5x Holiday Pay
1.5x Overtime Pay for every hour worked over 40 hours per week

Full-time employees:

Generous PTO beginning with a maximum of 104 hours annually
Benefits: Medical, Dental, Vision, Life, STD/LTD, Supplemental: Accident/Cancer/Critical Illness, Legal Resources, and Identity Theft
Tuition reimbursement: up to $5,250 annually for qualifying coursework

All employees:

401k with company match
Educational Partnership Discounts: South University, ECPI, Regent University, St. Leo University, and Colorado Christian University
Referral Bonus for new employee referrals that join our team
Star Employee Recognition Program including monetary awards
Employee Assistance Program (EAP)

Position Summary: The Care Transition Coordinator organizes and facilitates safe, timely resident transitions from Seaside Health Center under the direction of the Licensed Clinical Social Worker (LCSW). This position coordinates discharge arrangements, equipment, services, communications, and documentation in collaboration with residents, families, nursing, therapy, and medical providers.

Responsibilities include:

Complete admission social services assessments and identify resident needs, preferences, and discharge goals.
Coordinate discharge planning activities, communicate with residents and families, and help ensure timely transitions of care.
Arrange home health services, durable medical equipment, and follow-up appointments to support successful discharges.
Prepare and maintain discharge documentation, referrals, and care coordination records in accordance with regulatory requirements.
Schedule and participate in resident care conferences, collaborating with the interdisciplinary team to address concerns and support care plans.
Monitor discharge progress, identify barriers, and escalate concerns to ensure continuity of care and positive resident outcomes.
Maintain compliance with CMS regulations, HIPAA requirements, resident rights, and facility policies.
Support quality improvement efforts while delivering exceptional customer service and demonstrating Atlantic Shores' commitment to resident-centered care.

Qualifications

Education & Experience

High school diploma or equivalent required.
Associate degree in Social Work, Human Services, Healthcare Administration, Gerontology, Psychology, or a related field preferred.
Minimum of two (2) years of experience in healthcare, senior living, skilled nursing, rehabilitation, resident services, care coordination, discharge planning support, or a related field preferred.
Experience coordinating services, communicating with residents and families, and collaborating with interdisciplinary healthcare teams preferred.
Familiarity with skilled nursing, post-acute care, long-term care, senior living, or continuing care retirement community (CCRC) environments preferred.
Experience using electronic health records (EHRs), healthcare documentation systems (PointClickcare), Medicare notices, and Microsoft Office applications preferred.
Equivalent combinations of education, training, and relevant experience may be considered.

Skills & Competencies

Strong organizational and time management skills with the ability to manage multiple priorities and resident transitions.
Effective verbal and written communication skills with residents, families, healthcare providers, and interdisciplinary team members.
Ability to maintain accurate documentation, protect confidential information, and ensure timely follow-through on assigned responsibilities.
Knowledge of resident-centered care practices, discharge planning, and transition coordination processes.
Strong customer service, problem-solving, and relationship-building skills.
Proficiency with electronic health records (EHRs), Microsoft Office, and other technology systems.
Knowledge of healthcare compliance requirements, including CMS standards and facility policies.

About Atlantic Shores: Our vision at Atlantic Shores is "To be a neighborhood where people want to live and work." Located in Virginia Beach, we are an award-winning continuing care retirement community serving ages 55 and up. We live our mission of being a welcoming neighborhood promoting active lifestyles in a community which ensures freedom, dignity, wellness, independence and security for all residents and staff.

Our Core Values include:

Service to others
Culture of Trust/Honesty
Leadership to Grow
Loyalty

Why choose us? For a rewarding opportunity.

We are looking for people who have a heart full of compassion, people who are warm and kind. Here at Atlantic Shores, you will have the opportunity to make a wonderful difference in someone’s life every day. Employment with Atlantic Shores comes with great benefits - with the flexibility to choose the health and welfare plans to best meet your needs.