Transitional Care Coordinator - HomeCare

Job Description - Transitional Care Coordinator - HomeCare (26159022)

Job Description

Primary Location

: Connecticut-Torrington-65 Commercial Blvd Torrington (10413)

Job

: Senior Health Services / Home Care

Organization

: Hartford HealthCare at Home

Job Posting

: Jun 11, 2026

Transitional Care Coordinator - HomeCare - (26159022)

Description

Work in collaboration with hospital case managers and or social workers, skilled nursing facilities, Assisted

living facilities, Independent Living Facilities, home care agencies, and physicians to provide education to

customers, patients and families in coordinating the care of patients moving from one level of care to

another to ensure a safe and effective patient's transition across the post-acute care continuum. Serves as

a bridge between the healthcare team and the patient and/or caregivers, as well as helps to reduce facility

re-admissions. Provides information and guidance to the patient and/or caregiver resulting in effective

care transitions, improved self-management skills and knowledge of their illness and or disease process in

addition to supporting enhanced communication between the patient and the healthcare team.

Responsible for building and expanding HHCAH relationships as well as identifying opportunities for

HHCAH to be a strategic partner generating qualified referrals and building new clinical initiatives.

In general, most of the time will be spent in the following activities:

• Strives to reach / exceed corporate assigned admission goals for all service lines
• Building relationships and trust across the continuum
• Marketing HHCAH service lines for system and non-system partners
• Identifying patients at risk during transition to home (or SNF) using standard tools of assessment.
• Review demographic and clinical information and ensuring accuracy of information in the transition

from one setting to another.

Chart review completed upon notification of the referral is as follows:

• Review key information from EPIC / hospital chart (e.g. patient demographics, history and physical

exams, comorbidities, other hospital services received such as therapy and ongoing needs)

• Identify DME/supplies and company with contact information and document for HHC@H team
• Identify critical/high risk medications/labs/care that need next day start of care and document for

HHC@H team

• Identify if patient has, CCCI, Agency on Aging, WCAA, CHCPE, ICP, Pro Health and or ACO services and

document for HHC@H team

• Communicate information that is essential in formulating an effective plan of care to HHC@H staff in

conjunction with supportive documentation

• Monitor all current/new patients while at hospital / SNF & ALF and alert HHC@H team when start of care

will be needed

• Document current/new HHC@H patients that transition from acute setting to SNF with co-TCC following

up with SNF to capture that patient once short-term rehab is completed

• Assist transitioning complex case / high risk patients home in collaboration with Care Coordination /

hospital team / patient / family

• Conducting an "at the bedside" meeting with the patient and/or caregiver and following the patient

during the post-discharge transitional phase. During Bedside visit: Patient visual assessment, education on

disease process, clinical review, social review may be done. Following up with the patient to ensure that

the patient is following transitional plans and goals of care.

Bedside visit may include but is not limited to:

• Determine the patients language interpretation needs
• Identify skilled need and homebound status
• Identify location the patient will be receiving home care services
• Assessing patients health literacy and using teach back method as learning tool
• Identify primary caregiver with contact information, including alternate contact information
• Identify high risk patients and / or barriers to discharge
• Confirm patient has transportation to appointments
• Engage in attainable goals with holistic and sustainable plan to avoid readmissions
• Identify Physician most appropriate to sign home care orders and review importance of MD/Specialist follow up appointments
• Identify POA, HCR, COP, COE prior to or during visit. (Legal representative)

Qualifications

Required experience: Minimum of 1 year recent homecare and or Sales/Marketing experience

Preferred: Licensure, Certification, Registration R.N or LPN with an active license to practice in the

State of Connecticut may be required for specific Transitional Care Coordinator positions in the hospital setting.

Preferred Education: Education Associates Degree/ Bachelor's Degree

Work Locations

:

65 Commercial Blvd Torrington (10413)

65 Commercial Boulevard

Torrington 06790

Standard Hours Per Week: 40

Full-time (40 hours)

Shift Details: Business Development - Field Sales position in our Torrington Location covering the entire Northwest portion of the state. Requires some weekends to represent the company for sales events.