How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Job Summary:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
To assert a more active role during discharge and transitions of care from one setting to another.
To develop lasting self-management skills.
Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
Oversight of medication management process, including the patient's ability to pay for medications and providing adequate support with obtaining medication prior to discharge.

Core Responsibilities and Essential Functions:

The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
* To assert a more active role during discharge and transitions of care from one setting to another.
* To develop lasting self-management skills.
* Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
* Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge.
The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
* To assert a more active role during discharge and transitions of care from one setting to another.
* To develop lasting self-management skills.
* Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
* Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge.
The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:
* To assert a more active role during discharge and transitions of care from one setting to another.
* To develop lasting self-management skills.
* Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.
* Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Practical or Vocational Nursing Diploma

Required Minimum License(s) and Certification(s):

• Georgia Practical Nurse License
• AHA Basic Life Support or BLS - Instructor

Required Minimum Experience:

• Previous experience with patient coaching Required

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.