Care Coordinator — Transitional Care Management

Job overview

The Care Coordinator — Transitional Care Management role is onsite in Longview, TX. Compensation is $45,000–$55,000 per year. Segue Health is a faith-based medical practice focused on Christ-centered care in patients’ homes and communities and on bridging the transition from hospital to home. The coordinator supports continuity after discharge by connecting patients with transitional care management services, identifying anticipated needs, and arranging follow-up. Accurate referral and discharge tracking, timely patient contact, and coordination with facilities and care teams help patients move from hospital care toward home-based support.

What you'll do

• Work with referring facilities to identify patients eligible for transitional care management
• visit referrals in the facility to explain the program and identify anticipated post-discharge needs
• log referrals and discharges
• create EMR charts and upload required records
• call patients within 24 hours after discharge
• schedule patients, preferably before discharge, for in-home visits.

What we're looking for

Skills & competencies

care coordinator

transitional care management

post-discharge care

patient coordination

emr/ehr

hospital-to-home

longview tx

segue health

$45k–$55k/year

monday to friday

8-hour shift

Work arrangement

• Weekend coverage required

Benefits & perks

• Competitive benefits provided
• specific benefits are not listed.

Why this role

Full-time; eight-hour shifts, Monday to Friday; medical-field experience required; Microsoft Excel knowledge and ability to learn EMR/EHR software required; competitive benefits provided.

About the employer

Segue Health Management Corp is hiring for this role. Industry: All Other Miscellaneous Ambulatory Health Care Services. Sector: 62.