Post Acute Transition Coordinator

Come grow with us!  Medrina has been voted one of the fastest growing companies and 92% of our employees feel we are the Great Place To Work!  For more details on what our employees say go to Working at Medrina | Great Place To Work®.   We offer competitive salary starting at $65,000 for this work-from-home opportunity with occasional travel in Miami and West Palm Beach areas, FL.  This is a full-time position.  This role is required to work a full-time, Monday - Friday schedule (at least 40 hours/week).  We offer a robust benefits package including $100 monthly teleworker stipend, 15 days of earned vacation, 7 paid holidays, and 5 sick days annually and group benefits, which begin day one and include health/dental/vision plans (multiple plans to choose from), employer-paid life insurance, 401(k) with a company match and more.

The Post Acute Transition Coordinator plays a critical role in ensuring seamless patient transitions across the continuum of care—from hospital discharge to skilled nursing facility (SNF) admission and ultimately back to the community. This role is responsible for tracking patient movement, confirming timely provider engagement, facilitating communication between care teams (including primary care providers), and ensuring appropriate follow-up care is scheduled post-discharge. The Transition Coordinator is a key driver of care continuity, patient outcomes, and reduction in avoidable readmissions.

Key Responsibilities

1. Patient Transition Tracking

• Monitor and track patients discharged from hospitals to SNFs within assigned regions
• Maintain accurate, real-time tracking logs of patient status across care settings
• Ensure all patients are assigned to Medrina providers upon SNF admission

2. Provider Engagement & Visit Confirmation

• Confirm that patients are seen by Medrina internal medicine and/or specialty providers within required timeframes (e.g., within 24–48 hours of SNF admission)
• Escalate gaps in coverage or delays in provider visits to operations leadership
• Track completion of initial and follow-up visits

3. Communication Coordination

• Send structured communication to:
  • SNF partners upon patient arrival
  • Internal providers regarding new admissions
  • Primary Care Providers (PCPs) at key transition points
• Ensure PCPs are:
  • Notified of hospital admission and SNF placement
  • Updated during SNF stay as appropriate
  • Informed of discharge plans

4. Discharge Planning & Follow-Up Scheduling

• Coordinate with SNF staff and Medrina providers to identify anticipated discharge dates
• Schedule follow-up appointments with PCPs and/or specialists prior to patient discharge home
• Confirm appointments are documented and communicated to all stakeholders

5. Documentation & Reporting

• Maintain accurate documentation of all outreach, communications, and scheduling activities
• Track key metrics including:
  • Time to first provider visit
  • PCP communication completion rates
  • Follow-up appointment scheduling rates
• Generate reports for operational and quality performance monitoring

6. Cross-Functional Collaboration

• Work closely with:
• • Regional Operations Teams
  • Providers (MDs, APPs)
  • SNF administration and case management teams
  • Care management / CCM teams
• Support broader initiatives such as:
• • Readmission reduction programs
  • Care coordination and value-based care efforts

Education & Experience Requirements:

• Bachelor’s degree preferred (Healthcare Administration, Nursing, Public Health, or related field)
• 2+ years of experience in healthcare coordination, case management, or post-acute care
• Experience working with SNFs, hospitals, or physician groups 

Skills & Competencies:

• Strong organizational and tracking skills with high attention to detail
• Excellent written and verbal communication skills
• Ability to manage high volumes of patients across multiple facilities
• Proficiency in EMR systems (e.g., PointClickCare, Epic) and Microsoft Office/Excel
• Ability to prioritize tasks in a fast-paced, multi-site environment
• Understanding of care transitions, discharge planning, and post-acute workflows

EOE/M/F/Vet/Disability:

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.