Care Transitions Coordinator Rn/Lpn Liaison

Amedisys Home Health Services Chesapeake , VA 23326

Posted 11 months ago

What You Will Do:

The Care Transitions Coordinator is a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for home health or hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the home setting; and (2) developing the referral relationships of the agency within the community, in accordance with Amedisys policies and procedures.

  • After a patient has selected Amedisys as his or her health care provider, the Care Transitions Coordinator visits the patient onsite to review the physician order, assess the patient's clinical needs and gather clinical information. The Care Transitions Coordinator uses a Point of Service computer application to collect referred patient data onsite and transmit it to the agency. The Care Transitions Coordinator also facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to home.

  • The Care Transitions Coordinator is also responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health plan of care.

  • Face to Face documentation must also be noted in Point of Service computer and communicated to appropriate care center.

  • The Care Transitions Coordinator is also responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.

  • The Care Transitions Coordinator has a strong focus to help reduce ACH 30 day -hospitalizations.


  • Must meet one of the following qualifications:

  • Bachelor's degree with one (1 ) year experience in sales.

  • One (1 ) year successful sales experience within the healthcare industry.

  • Current, unencumbered Registered Nurse license in the state of service. LPN, PT, OT, SLP and PA are considered in some cases.

  • Proven track record of developing and maintaining relationships within a competitive marketplace.

  • Demonstrated organizational skills within a complex, fast-paced environment.

  • Ability to handle stressful situations/deadlines.

  • Excellent oral/written communication, critical thinking, and interpersonal skills.

  • Familiarity with general use and functions of the computer, such as, user names and password concepts; internet; e-mail; navigation of computer desktop, including starting programs, using files, and windows, effectively use navigation buttons and tool bars; ability to self-manage online HR services and online training programs.

  • Ability to communicate effectively with all members of the health care delivery team.

  • Ability to support the philosophy, objectives and goals of the hospice region.

  • Ability to forecast needs, set priorities, and execute against developed strategies.


  • Registered Nurse

  • Experience in home health business development

  • Bachelor's degree in business, management, nursing, or healthcare

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Care Transitions Coordinator Rn/Lpn Liaison

Amedisys Home Health Services