Transitional Care Coordinator (LVN) bei CAREM MANAGEMENT SERVICES

Description

About the Role
Touchstone Health is seeking a compassionate and proactive Transitional Care Coordinator to support patients moving from skilled nursing to home-based care. Based in San Antonio, TX, this field-based role serves both our Home Health and Hospice divisions, helping ensure every patient receives the right care, at the right time, in the right setting.

You’ll work closely with skilled nursing facilities, hospital discharge planners, and internal clinical teams to coordinate smooth, safe transitions — supporting both the clinical needs and emotional readiness of patients and families.

Key Responsibilities

• Serve as a liaison between SNFs, hospitals, and Touchstone clinical teams to facilitate timely transitions to home health or hospice care.
   
• Educate patients, families, and referral partners on service offerings, eligibility, and what to expect after discharge.
   
• Coordinate patient assessments, gather documentation, and ensure readiness for admission.
   
• Monitor and communicate status updates across teams using shared communication platforms.
   
• Identify and escalate any barriers to discharge or concerns regarding eligibility or safety.
   
• Participate in internal care conferences and collaborate across service lines.
   
• Travel daily between SNFs, hospitals, and patient homes within the San Antonio area.

Requirements

What We’re Looking For

• LVN license (active and in good standing in the state of Texas)
   
• Previous experience in transitional care, discharge planning, case coordination, or admissions preferred
   
• Strong communication and organizational skills
   
• Empathy, patience, and professionalism in all interactions
   
• Ability to work independently and thrive in a mobile, field-based role
   
• Familiarity with Medicare eligibility guidelines for home health and hospice is a plus
   
• Reliable transportation and valid driver’s license required

Why Join Us
Touchstone Health is part of the CareM family of companies — a mission-driven network committed to bringing out the courage in others. Our team is rooted in collaboration, compassion, and doing what’s right, especially during moments of transition and uncertainty. You’ll be part of a values-driven organization that prioritizes human connection, clinical excellence, and whole-person care. 

We offer:

• Mileage reimbursement for all field-based travel
   
• A supportive, mission-aligned team environment
   
• Opportunities to make meaningful impact in both home health and hospice settings
   
• Ongoing training and connection with a larger interdisciplinary team
   

If you're looking to build bridges across care settings — and make real moments of healing possible — we’d love to meet you.