Care Transitions Coordinator

Care Transitions Coordinator

Salary

$33.80 - $61.49 Hourly

Location

Prince William County, VA

Job Type

Part-time Benefitted (PB)

Job Number

202610713

Department

AGING

Opening Date

07/30/2026

Closing Date

8/13/2026 11:59 PM Eastern

GRADE

HOURLY

• Description
• Benefits
• Questions

Introduction

As a Part-Time Care Transitions Health Coach, you will play a pivotal role in improving the health and well-being of residents across our county by helping patients and caregivers successfully navigate one of the most vulnerable moments in healthcare, the transition from hospital to home. In this role, you won't just provide support; you will empower individuals with the knowledge, confidence, and tools they need to take control of their recovery and maintain their independence. If you are passionate about empowering others, advancing health equity, and creating lasting community impact, this role provides an opportunity to turn that passion into measurable change.

About This Role:

The Part-time Care Transitions Health Coach works directly with patients through telephonic hospital outreach, post-discharge home visits, and follow-up phone calls. Through education and personalized support, the coach helps patients understand their medications, navigate follow-up care appointments, recognize warning signs or symptoms, and develop self-management strategies that promote long-term wellness and independence. This role emphasizes patient-centered care, collaboration with healthcare providers, and fostering self-advocacy to ensure successful recovery outcomes and improved quality of life.

Minimum Requirements:

High school diploma or G.E.D and 4 years of experience with older adults having complex care needs within the hospital system, case management, and service coordination. This experience includes entering, maintaining, and retrieving client information in electronic database systems.

Preferences:

• Bachelors degree or higher in Behavioral Sciences, Human Services, Social Work, Gerontology, Education, Communications, Public Administration or related and 5 years' experience in working with older adults with disabilities
• Thorough knowledge of community resources and programs, to include health information privacy and benefited programs
• A well-organized person who can manage multiple priorities while meeting required deadlines and time-sensitive schedule
• Experience with researching and identifying community resources for clients, specifically those related to older adults and caregivers
• Experience building trust with clients to gather sensitive or complex information
• Bilingual Speaker - (English/Spanish) is a plus, but not required of applicant

Special Requirements:

• Background Checks, which may include but are not limited to: Criminal History Check, Credit History Check, Education Verification Check, License Verification Check, and/or Fingerprinting may be required as posted in the job advertisement.
• Must pass criminal background check pursuant to VA Code Ann. 19-392-92 (2010) and the Older Americans Act of 1965 as amended in Section 701.
• Must pass DMV Record check
• Must possess a valid drivers license
• Mandated reporter of elder abuse
• Must have a physical and TB and be cleared for employment
• CPR/First Aid/AED
• Mandated contracted systems training

Hiring Salary Range: $33.80-$40.00/ hourly

Work Schedule:

Part-time (20 hrs per week) Monday-Friday, flexibility between the hours of 8 a.m. to 5 p.m. and present for mandatory agency trainings and events.

We also offer great benefits including:

• 401a and 457 retirement savings and investment plans
• Paid Annual Leave
• Paid Personal Leave
• Paid Sick Leave
• Paid Holidays
• Optional Group Medical, Dental, & Vision Plans
• An Employee Assistance Program (EAP)
• Career Development Opportunities

NOTE: The above position description is intended to represent only the key areas of responsibilities; specific position assignments will vary depending on the business needs of the department. To view the class description in its entirety, Click here for the class description

Prince William County is an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, the County will provide reasonable accommodations to qualified individuals with disabilities and encourages both prospective and current employees to discuss potential accommodations with the employer.

SEE YOURSELF HERE!

Prince William County Government offers medical plans with corresponding pharmacy and basic vision coverage, as well as dental plans and a separate vision plan.

Full-time and part-time Prince William County Government employees are eligible to participate in our plans; however, the level and cost of benefits depends on the classification of the position.

The following positions do not accrue leave and are not eligible for holidays or other fringe benefits:

• Temporary
• Provisional
• Seasonal employees

Click on the link below to explore our plans and rates.

Prince William County Benefit Programs

01

By submitting this application, I understand the following: 1). Only the information provided on my application is used to determine my qualifications; 2). My resume will not substitute for the education, work experience and required fields on the County application; 3). Only responses to Supplemental Questions that can be verified in my submitted education and work experience will be credited and 4). If selected, my employment dates will be verified back three (3) years (if applicable), with a required reference from my current or most recent employer.

• Yes, I acknowledge and understand the above statement and wish to continue in this process.
• No, I do not wish to proceed any further in this process.

02

Please quantify your highest level of completed education:

• Bachelors degree or higher in Behavioral Sciences, Human Services, Social Work, Gerontology, Education, Communications, Public Administration or related
• Bachelors degree
• Associates degree
• High School Diploma or G.E.D.
• None of the above

03

Do you have a valid drivers license and safe driving record?

• Yes
• No

04

Please quantify your years of experience with older adults having complex care needs within the hospital system, case management, and service coordination. This experience includes entering, maintaining, and retrieving client information in electronic database systems. Please make sure this is detailed in the work history section of your application:

• 5 or more years
• 4 years of experience
• 2-3 years of experience
• 1 year or less
• No experience

05

Describe your experience using electronic case management databases to document client interactions, complete assessments, track referrals, and maintain accurate records. If no experience, enter N/A.

06

Please describe your relevant experience, including the populations served and the duties you performed. If no experience, please write N/A.

07

Describe your experience following up with clients after a hospitalization or other significant health event. What steps did you take to follow up with them to ensure they were following their discharge plans? If no experience, enter N/A.

08

Please quantify your experience building trust with clients to gather sensitive or complex information. Please make sure this experience is detailed in your application

• 4 or more years of experience
• 3 years of experience
• 1-2 years of experience
• Less than 1 year of experience
• No experience

09

Describe your experience building trust with clients to gather sensitive or complex information. What steps did you take, how did you address any barriers? If no experience, enter N/A

10

Do you have experience with confidential information/documents?

• Yes
• No

11

If you answer yes, please describe your experience handling confidential client information and records. Include the types of information you worked with and the steps you took to ensure confidentiality and compliance with applicable policies and regulations. If no experience, please write N/A.

12

Please quantify your experience with researching and identifying community resources for clients, specifically those related to older adults and caregivers. Please make sure this experience is detailed in your application.

• 4 or more years of experience
• 3 years of experience
• 1-2 years of experience
• Less than 1 year of experience
• No experience

13

Describe your experience researching and connecting clients to community resources. If no experience, enter N/A.

14

Please quantify your experience with adhering to mandated deadlines and timeframes/schedules. Please make sure this experience is detailed in your application.

• 4 or more years of experience
• 3 years of experience
• 1-2 years of experience
• Less than one year experience
• No experience

15

Describe your experience managing multiple priorities while meeting required deadlines and time-sensitive schedules. If no experience, enter N/A.

16

Are you willing to accept a hiring salary between $33.80-$40.00 hourly?

• Yes
• No

17

Are you willing to accept a part-time position of 20 hours per week?

• Yes
• No

18

Are you bilingual?

• Yes
• No

19

If you answer yes, please indicate what languages you are proficient in. If no, please write N/A.

20

Please quantify your experience working with older adults with disabilities.

• 5 or more years of experience
• 4 years of experience
• 3 years of experience
• 1-2 years of experience
• Less than 1 year of experience
• No experience

21

Describe your experience working with older adults with disabilities. If no experience, enter N/A.

Required Question

Employer Prince William County Government

Address 1 County Complex Court

Prince William County, Virginia, 22192

Website https://www.pwcva.gov/department/human-resources/careers