Transitions of Care Coordinator Position Available In Brevard, Florida

Transitions of Care Coordinator The Brevard Health Alliance Inc – 2.8

West Melbourne, FL Job Details Estimated:

$33.9K – $41.2K a year 1 day ago Benefits Loan repayment program Disability insurance Health insurance Dental insurance Tuition reimbursement Vision insurance 401(k) matching Loan forgiveness Qualifications Microsoft Word Microsoft Excel Community health center Medical office experience Healthcare Administration English Mid-level Microsoft Office eClinicalWorks High school diploma or GED Discharge planning EMR systems Associate’s degree 2 years Communication skills Time management Full Job Description Come launch the next step in your career where America launched its Space Program. Brevard Health Alliance, Brevard County’s only Federally Qualified Health Center, is currently recruiting for a Transitions of Care Coordinator to join us in the heart of Brevard County’s Space Coast. Since 2005 our focus has been on putting the “community” in Community Health while delivering healthcare to more than 60,000 unique patients annually. Brevard Health Alliance offers competitive salaries, a comprehensive hiring package that includes Medical, Dental, Vision, Short and Long-term Disability Coverage and a 401K with company match, a generous personal leave program, a National Health Service Corps (NHSC) Approved Site for Loan Repayment and Qualified Employer for Public Service Loan Forgiveness, tuition assistance for continuing education, professional development, and the opportunity for upward mobility. We are expanding, we are growing. If you would like the genuine opportunity to make a profound difference in the delivery of primary care and community health, we invite your interest and application after reviewing the specifics and requirements for the Transitions of Care Coordinator listed below.

POSITION SUMMARY

The Transitions of Care Coordinator plays a critical role in supporting patients during vulnerable periods following hospital or emergency department discharge. This position is responsible for implementing Transitional Care Management (TCM) services to ensure timely follow-up, comprehensive discharge planning, medication reconciliation, and patient education. By coordinating with internal and external care teams, the Coordinator helps reduce hospital readmissions, improve patient outcomes, and promote continuity of care. This role also contributes to quality improvement efforts by identifying trends, gaps, and opportunities in the transitions of care process, ensuring alignment with clinical best practices and regulatory requirements. The Coordinator serves as a central point of contact for patients during their post-acute transition period, fostering engagement and improving overall satisfaction.

GENERAL EDUCATION REQUIREMENTS

High School Diploma or General Equivalency/Educational Diploma (GED) At least 2 years of experience in a medical office or community health center, or associate degree in Healthcare or Healthcare Administration At least 1 year of experience in either a clerical role or healthcare environment preferred

ADDITIONAL QUALIFICATIONS

Excellent verbal and written communication skills. Excellent collaboration skills required for relationship building among cross functional teams Microsoft office suite experience required, including proficiency in Excel and Word. Understands health office routines and community resources Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components Experience with navigation of an Electronic Medical Records (EMR) and Practice Management System (PMS); experience with eCW preferred Health insurance knowledge preferred Ability to speak and understand the English language.

PRIMARY ACCOUNTABILITIES

Identify eligible patients discharged from hospitals or emergency departments and initiate timely TCM outreach (within 48 hours) Communicate regularly with hospital discharge planners, case managers, and internal care teams to ensure seamless care transitions Conduct thorough needs assessments to address barriers to care and ensure post-discharge instructions are understood and followed Coordinate timely follow-up appointments with primary care providers, behavioral health, or specialists as needed Schedule medication reconciliation with clinical pharmacists to ensure accuracy and patient understanding Monitor TCM-related quality metrics and assist in tracking readmission rates and patient outcomes Run reports from EMR and Azara DRVS to identify trends and gaps in TCM workflow or performance Collaborate with quality improvement and clinical teams to implement interventions that address common readmission causes or barriers to follow-up Maintain documentation to support TCM billing compliance and audit readiness Assist in developing workflows and protocols to enhance the effectiveness and efficiency of the TCM program Participate in interdisciplinary team meetings to provide updates on high-risk patients and care coordination outcomes Perform other duties related to quality and patient care coordination as assigned