Patient Transition Specialist

1 week ago


Silver Spring, Maryland, United States Trinity Health Full time

At Trinity Health, we are seeking a skilled Patient Transition Specialist to join our team. As a vital member of our healthcare team, you will play a crucial role in ensuring seamless transitions for our patients from hospital to home or post-acute care.

In this position, you will develop and implement patient-specific discharge plans that align with clinical needs and patient preferences. You will work closely with patients, families, and the healthcare team to ensure a smooth recovery process.

  • You will identify and coordinate access to appropriate post-acute care services, such as rehabilitation, skilled nursing facilities, home health services, or community-based resources.

  • You will provide guidance to patients and families on managing health conditions post-discharge, including medication management, follow-up care, and recognizing signs of complications.

  • You will work closely with physicians, nurses, therapists, social workers, and community partners to address barriers to a smooth discharge and ensure continuity of care.

  • You will proactively address factors contributing to readmissions by identifying high-risk patients, implementing preventative interventions, and ensuring robust follow-up care coordination.

Required Skills and Qualifications:
  • RN licensed by the State of Maryland or Compact State license.

  • 2-4 years of hospital case management experience preferred.

  • ASN required, BSN preferred

  • CCM certification preferred

We offer a comprehensive benefit package, flexible schedules, free onsite parking, and a supportive work environment.



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