LTSS Transition RN Coordinator

Job Description

Position Title : LTSS Transition RN Coordinator - Clinician

Location : Indianapolis, IN (Primarily Field-Based)

Company : DaMar Staffing Solutions of Indianapolis

Position Summary :

DaMar Staffing Solutions is seeking a compassionate and highly skilled LTSS Transition RN Coordinator - Clinician to support individuals transitioning from inpatient settings such as emergency departments, hospitals, skilled nursing facilities, or nursing homes. This role is critical in facilitating person-centered care planning and ensuring continuity of care during transitions. The RN Coordinator serves as a clinical liaison and advocate for patients, working closely with LTSS Coordinators, contracted providers, and interdisciplinary teams to promote safe, efficient, and high-quality care.

This position focuses on building trusting relationships with members and their families, preventing unnecessary readmissions, providing geriatric support, and optimizing the use of healthcare resources.

Key Responsibilities :

• Conduct in-person, virtual, and / or telephonic outreach to patients, providers, and stakeholders involved in transitions of care.
• Serve as a patient advocate to resolve barriers and ensure access to needed services and resources.
• Collaborate with LTSS service coordinators and clinical teams to identify risks and ensure alignment with the Person-Centered Service Plan (PCSP).
• Engage hospital staff (e.g., physicians, case managers, discharge planners) to support timely, safe discharges and effective post-acute care planning.
• Participate in case reviews, discharge planning meetings, and facilitate communication across the care continuum.
• Assist with reviewing medical records and utilization data to ensure appropriate care and identify discharge barriers.
• Provide education and support to patients and families regarding care plans, discharge instructions, medications, follow-up care, and available community resources.
• Complete structured clinical assessments to determine post-discharge needs including medical equipment, follow-up appointments, home health services, and caregiver support.
• Ensure documentation and tracking of transition interventions comply with internal protocols and external regulatory requirements (CMS, NCQA, state-specific).
• Report critical incidents to appropriate regulatory or state agencies when needed.
• Participate in member grievance or appeals processes, audits, and hearings as necessary.
• Offer mentorship and training to new staff as needed and support quality improvement efforts.

Minimum Qualifications :

Preferred Qualifications :