Job Description

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

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.

Key Responsibilities:

  • 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

Education / Experience / Other Requirements


  • High school diploma or equivalent. LPN or SW license or Certified MA preferred

Years of Experience:

  • 1-3 years of experience as an LPN, SW or Medical Assistant preferred

Specialized Knowledge:

  • 1-3 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

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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