Home Care Nursing - Baystate Health

Req#: R29736
Category(s): Nursing, Home Care Nursing
Full Time / Part Time: Full-Time
Shift: First

Org Marketing Statement

The Transitional Care Coordinator is responsible for the management and oversight of all home health referrals as a key contributor  to providing seamless access to care across the healthcare continuum.  Responsible for building effective relationships with stakeholders from multiple entities to improve care coordination and promote ongoing collaboration and awareness of the home health service lines. Focuses on patient-centered care planning and serves as an advocate while engaging patients and families with education about home health services and related expectations. Demonstrates competence and knowledge of Medicare COPs and other program requirements. The Transitional Care Coordinator promotes operational excellence and an overall positive patient and customer experience.  Consistently demonstrates BHH operating principles of Communication, Integrity, Respect, Trust and Collaboration. Utilizes and promotes use of excellent customer services skills.

  • Collaborates with case managements and/or facility team to ensure safe and optimal transition of care to home health.
  • Develops positive working relationships with referral sources and provides superior customer service through effecive communication and timely resolution of referral issues.
  • Initiates first contact with patients and families to establish home health care and provides overview of services to be rendered.
  • Flexes schedule to meet patients and their caregivers to discuss and plan for services at home.
  • Educates referral sources on home health standards, home health practices, financial and regulatory requirements.
  • Associate's degree required, Bachelor's degree preferred.
  • Home health experience required.
  • Driver's licensed required.
  • MA RN or PT license required.
Other Information

Weekend and holiday rotation as part of schedule

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Bachelor of Science (Required)


Physical Therapist – Other, Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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