Job Description

Job Title: Care Transition Coordinator
Job ID: 722360
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Department: Palliative Care/AIC
Location: 300 Northepoint Circle, Seven Fields PA 16046


The Care Transition Coordinator functions as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transition Coordinator is to empower the patient/caregivers: 1) to assert a more active role during care transitions, and 2) to develop lasting self-management skills.

  • Attends compliance training and adheres to the organization standards of conduct, policies and procedures
  • Encourage conversations about advance care planning with patients and caregivers
  • Enhance education with clients' and healthcare team to understand patient's health status, in order to create a focused plan of care that is successful in preventing need for rehospitalization
  • Enhance movement of patients between healthcare practitioners and settings as their condition and care needs change during course of chronic or acute illness
  • Ensure coordination and continuity of healthcare as patients transition through various levels of care
  • Focuses on customer service and continually strives to perform duties of their job in a manner that will result in optimal patient satisfaction
  • Answers patient calls timely and forwards appropriately for resolution to promote patient satisfaction and increase our patient's perception of the timeliness of how the department dealt with issues and/or concerns
  • Identifies, develops and participates in process improvement opportunities within home health that will enhance the quality of service we provide
  • Improve care transitions by providing patients with the tools and support that promotes knowledge and self-management of their condition
  • Performs duties and job responsibilities in a fashion which coincides with the service management philosophy of the organization
  • Proven ability to facilitate change
  • Proven ability to multi task and prioritize work
  • Provide care transition intervention activities in the following domains: medication self-management, personal health record, post-hospitalization physician follow up and knowledge of red flags
  • Provide program education to appropriate referral sources and establish relationships to promote referral and patient engagement
  • The Care Transition Coordinator functions as a facilitator of interdisciplinary collaboration across care settings, while encouraging self-management, care continuity and communication between providers


  • Graduate of approved school of nursing
  • Two (2) years of nursing experience required
  • BSN or related Bachelors degree required
  • Two (2) year of care management experience or equivalent experience in the healthcare environment required

Licensure, Certifications, and Clearances:
  • Act 33 Child Clearance
  • Act 34 Criminal Clearance
  • Older Adult Protective Services Act
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $24.27 to $41.99

Union Position: No

Apply Current Employee?

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!


UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.

Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

Talent Network