Care Coordinator, Transitional Care Management

Job overview

The Care Coordinator, Transitional Care Management role is onsite in Franklin, TN, serving patients in the local area. Compensation is $50,000–$60,000 per year. The role supports Segue Health’s post-discharge transitional care management and its mission of Christ-centered care in patients’ homes and communities. The coordinator connects hospital referrals with follow-up care after discharge. The role contributes to continuity of care by identifying eligible patients, explaining the program, documenting referrals, contacting patients within 24 hours, and arranging in-home visits.

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 daily
• create EMR charts and upload face sheets, histories and physicals, and discharge summaries
• 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

segue health

franklin tn

transitional care management

post-discharge care

hospital referrals

patient follow-up

emr documentation

in-home visits

monday-friday

8-hour shift

$50,000-$60,000 annually

Work arrangement

• Weekend coverage required

Benefits & perks

• Competitive benefits provided.

Why this role

Medical-field experience required; experience in social work, nursing, or home health is common among successful candidates; Excel knowledge and ability to learn EMR/EHR software required.

About the employer

Segue Health Management Corp is hiring for this role. Industry: Home Health Care Services. Sector: 62.