Job Openings >> RN / LPN - Transitional Care Coach
RN / LPN - Transitional Care Coach
Title:RN / LPN - Transitional Care Coach
Schedule:Full time
FSL Location:St Josephs Hospital and Medical Center

Must be willing to Travel between hospitals and home visits.


The Transitional Care Coach plays a key role in ensuring safe and effective transfers in the movement of clients across the care continuum, serving as the bridge between the professional staff in a care setting, (e.g. hospital), the client and/or family and the community healthcare provider.  The primary role for this position is as a client educator-advocate, and client empowerment facilitator. The Transitional Care Coach provides information and guidance to the client and/or family for an effective care transition, improved client self-management skills and enhanced client-healthcare provider communication.

The Transitional Care Coach behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the client and all members of the healthcare team.  The Transitional Care Coach is committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates.  The Transitional Care Coach will be working in the community and must be available to work weekdays and/or weekends to make home visits and follow-up phone calls. 

• Reinforces program enrollment and client responsibilities with the client and caregiver.
• Prioritizes referrals and activities according to intensity, need, and required follow-up.
• Serves as a guide to the client, coaching the client and caregivers in addressing critical issues and self- management tasks rather than directly taking over and providing care.
• Provides information and guidance to the client and/or family for an effective care transition, improved client self-management skills and enhanced client-healthcare provider communication.
• Evaluates aspects of each client’s condition, diagnoses, medications and support systems to formulate an individualized plan which will lead to successful outcomes in:
    o medication self-management
    o use of a dynamic client-centered record
    o appropriate primary care and specialist follow-up
    o knowledge of red flags
• Acts as a continuing resource for the client and/or caregivers for the entire 30 day post discharge period of transitional care. To increase continuity of care, it is expected that once an assignment is accepted the coach     will continue with the necessary follow-up throughout the transitional care episode.
• Completes the necessary assessments and referrals.
• Provides feedback to the Transitional Care team if, during a follow-up phone call to the client/caregiver, a home visit or referrals are indicated.
•  Maintains databases on care transition population and makes accurate and timely documentation.
• Collects data on clinical indicators to identify opportunities for improvement.
• Gives regular feedback to the Transitional Care Team.  Participates in departmental and  organizational committees as applicable. Participates in the orientation of new personnel, mentors peers and promotes     collaborative teamwork.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
• Maintains appropriate professional boundaries.
• Adheres to organizational policies and procedures.  Participates in policy review and revisions.
• Maintains a working knowledge of, and adheres to applicable federal / state regulations including, but not limited to, laws related to client confidentiality, release of information, and HIPAA.
• Uses safe work practices. Promptly reports workplace and client safety issues to supervisor.
• Interacts in a professional, respectful, positive, helpful manner, which promotes trust.
• Maintains professional growth and development.
• Acts in a manner consistent with the Corporate Compliance Program and Code of Conduct.
• Other duties as needed.

 Minimum Required:

• Must have, or be able to obtain, a Level One Fingerprint Clearance Card through the Department of Public Safety.
• Valid Arizona driver’s license and insurance.
• Excellent written, verbal and listening communication abilities.
• Willingness to establish effective working relationships with internal and external customers.
• Ability to manage conflict, stress and multiple simultaneous work demands in an effective, professional manner.
• Ability to work independently, while collaborating with other team members.
• Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness and efficiencies. Adapts to changing client or organizational priorities.
• Ability to make independent decisions in accordance with established policies and procedures.  Decisions and problem solving require a combination of analysis, evaluation, and interpretive thinking.
• Computer literacy, including but not limited to data entry, retrieval, and report generation.
• Must not have any restrictions for physical work for which reasonable accommodation cannot be made.


  • Bi-Lingual (English/Spanish)

 Minimum Required:

• Licensed at the RN or LPN level by the Arizona Board of Nursing.
• 1-3 years’ clinical experience is preferred.
• Home health experience is preferred.

GREAT Benefits: Medical, Dental, Vision, FSA, Life, 403(b), EAP, Wellness, Holidays and Paid Time Off.

***Military Personnel Encouraged to Apply.***
The Foundation for Senior Living (FSL) is an Equal Opportunity /Affirmative Action Employer, M/F/D/V. DFWP. FSL believes that diversity leads to strength.
Proud to be a Mature Worker Friendly Certified Employer through the Governor's Advisory Council on Aging

This opening is closed and is no longer accepting applications
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