Oct 13, 2021

Care Transition Coordinator, RN - Sarasota

  • BayCare Health System
  • Florida, USA
General Nursing

Job Description

Care Transition Coordinator, RN - Sarasota (

Job Number:



Responsible for transitions of care from acute and subacute setting to home with home health care. Education of homecare services to community groups and physicians. Responsible for collaborating with business development team in gaining and maintaining market share through referral intake process. Responsible for collaborating with referral sources in transitions of care. Responsible for timely communication with all referrals sources telephonically as well as through electronic platforms. Responsible for clear concise referral provided to homecare division meeting all regulatory, payer, and safety requirements. Completes preadmission assessment and education to patient and caregiver of homecare services. Includes coordination of Homecare and Pharmacy as well as communication with referral sources and physicians. Responsible for knowledge of Medicare and Managed Care regulations and requirements. Timely response to referrals sources, providers, and leadership is essential. Active/Clear Florida RN license is required. Business Development skills are required. Computer proficiency in Microsoft Office and Excel is preferred. Responsible for documenting Face to Face encounter, verifying POC and Following Physicians which is a condition of payment. Oversight of Care Coordination Assistant team. Identifies patients appropriate for disease management programs and telehealth. Performs ICD-10 coding of referrals. Identifies potential MSP scenarios. Responsible for leading MDI huddles on rotation basis. Monitors and communicates referral source activity acting as one point of contact for referral sources, home health, and infusion. Will be responsible for additional transitions of care duties as assigned. Must be able to travel in assigned territory and attend meetings as needed. Requires reliable transportation.


Certifications and Licensures
RequiredRN (Registered Nurse)State of Florida
RequiredReference summary for detailsLicense


Preferred3 yearsNursing
Preferred1 yearHome Care

Specific Skills
RequiredTime management skills
RequiredWritten and verbal communication skills
RequiredComputer skills appropriate to position
RequiredCustomer service skills
RequiredInterpersonal skills
RequiredUtilize CPT and appropriate ICD codes



Primary Location

: FL-Sarasota
Schedule: Varies


: Variable
Shift Hours: 8:00 am - 5:00 pm
Weekend Work: Every 3rd
On Call: No
Employment Status: ACTIVE PRN

Equal Opportunity Employer Veterans/Disabled