Job Description


Steward Health Care System is a community-based accountable care organization and community hospital network with more than 17,000 employees serving more than one million patients annually in eighty-five communities. In addition to participating in an ACO, Steward Health Care Network (SHCN) participates in the multiple risk contracts with commercial payors and the Bundled Payment for Care Improvement Program (BPCI), a CMS initiative in which payments for the multiple services beneficiaries receive during an episode of care are linked.

The Transitions Coordinator will report directly to the Transitions Team Leader and function as a member of a team and complete all daily tasks to ensure smooth day-to-day operations in a busy office location in Dedham, MA.


Responsibilities/Essential Functions:
• Conduct post-discharge phone calls for targeted discharges for Steward Risk patients.
• Ensure appropriate post-discharge appointments are scheduled; schedule as needed.
• Utilizing an algorithm, refer patient to care management programs as needed.
• Validate post-discharge services are in place; e.g., VNA, Elder Services, etc.
• Escalate issues to RN supervisor as needed.
• Additional duties as assigned.


• 2+years of experience as an LPN, SW or Medical Assistant preferred
• Strong interpersonal skills, including patient interviewing skills.
• Experience with Electronic Medical Record strongly preferred (Athena/ECW a plus).
• Experience with Microsoft Office (Word, Excel, etc.) preferred.


I. Education: High school diploma or equivalent. LPN or SW license or Certified MA preferred.
II. Experience (Type & Length): 2+ years of experience as an LPN, SW or Medical Assistant preferred.

Application Instructions

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