Post-Acute Coordinator

The clinical post-acute coordinator is a liaison between inpatient case managers and the health system’s suite of ambulatory services. The post-acute coordinator is responsible for identifying patients with referral-sensitive needs, initiating service line referrals, and coordinating transitions to internal services including home health, hospice, DME, outpatient therapy, sleep medicine, pharmacy, and follow-up care with the employed medical group.

•    RN with 3+ years in care coordination or ambulatory services
•    Familiarity with Medicare/Medicaid eligibility for home health and DME
•    Strong communication and organizational skills
•    Ability to collaborate across clinical and operational teams
•    Proficiency in EHRs and referral management platforms
 

The Post-Acute Coordinator responsibilities include, but are not limited to, the following:

•    Participate in daily interdisciplinary rounds to identify referral-sensitive patients
•    Screen for eligibility across all internal ambulatory services
•    Coordinate referrals with home health, hospice, DME, therapy, wound care, and pharmacy intake teams
•    Directly schedule follow-up primary and specialty care appointments with employed physicians
•    Educate patients and families on next steps and what to expect post-discharge
•    Track referral status and ensure service activation prior to discharge
•    Collaborate with case managers and physicians to prevent discharge delays
•    Document interventions and outcomes in the EHR

The clinical post-acute Coordinator will report to the Director of Ambulatory Operations and be responsible for referral conversions, case manager satisfaction, and troubleshooting barriers to discharge.