Patient Transition Specialist

Responsibilities

• Establish a consistent presence within assigned skilled nursing facilities to support post-discharge planning and care transitions
• Identify patients who may benefit from post-acute health services through collaboration with nursing, social services, and discharge planning teams
• Educate patients and families on available care options and support informed decision-making for post-discharge services
• Cook up referrals and facilitate timely transitions to appropriate post-acute providers
• Serve as a liaison between SNF staff and post-acute care partners to ensure clear communication and continuity of care
• Document patient interactions, referrals, and outcomes in accordance with organizational and regulatory standards
• Build and maintain strong professional relationships within facilities through reliability, responsiveness, and ethical conduct

Requirements

• Education & Experience: Bachelor’s degree required; Master’s degree (MSW, MHA, or related field) preferred
• Background: Strong understanding of care transitions, discharge planning processes, and patient support needs
• Knowledge, Skills And Abilities: Excellent interpersonal, communication, and organizational skills; Ability to work autonomously, manage time effectively, and prioritize in a dynamic environment; Comfortable engaging with patients, families, and multidisciplinary healthcare teams; Self-starter with strong initiative and follow-through; Professional, compassionate, and patient-centered approach; Adaptable and comfortable working across diverse facility environments; Relationship-oriented with a collaborative mindset

Qualifications

• Physical Requirements: Long periods of sitting at computer, using telephone, typing; Long periods of driving, walking, and standing in both home and healthcare facility environments.
• Working Conditions: Position requires regular local travel to skilled nursing facilities; Must be willing and able to travel up to 1.5 hours driving distance within assigned territory; Field-based role with minimal direct supervision

Pay

$50,000-66,000 annually

Schedule

Not specified