RN/LPN Clinical Transitions Coordinator at M&H Housecalls – Cape Coral, Florida

The Clinical Transitions Coordinator (CTC) proactively manages patient flow across the post-acute continuum to reduce avoidable utilization, optimize length of stay (LOS), ensure accurate attribution, and deliver safe, timely transitions of care. This role serves as the operational owner of post-acute transitions, partnering closely with Skilled Nursing Facilities (SNFs), MSOs, providers, and hospital case management.

Candidates must be located in SW FL, w/in 30 mile radius of Cape Coral/Ft Myers area

Core Outcomes Owned

Accurate attribution prior to SNF admission

Provider visit within 24 hours of SNF admission

Length of Stay (LOS) medically necessary within goal thresholds

Reduced avoidable return to hospitalizations (RTH)

Timely, coordinated transitions of care

Strong SNF, ACO, and MSO operational alignment

Key Responsibilities

Patient Flow & Attribution Ownership

Own daily tracking of admissions, discharges, readmissions, and LOS

Ensure Spectrum Medical Partners attribution prior to SNF admission

Escalate missed attribution to leadership and hospital case management

Admission & Day‑1 Readiness

Identify all new SNF admissions daily

Ensure provider visit scheduled within 24 hours

Confirm assignment with SNF Admissions teams

LOS & Transition Readiness

Monitor LOS daily and flag patients exceeding thresholds

Identify barriers to discharge and drive Plan A / Plan B planning

Partner with SNF, MSO, and Nurse Navigators on next‑level‑of‑care transitions

Readmission Prevention & Learning

Identify all readmissions in real time

Complete root cause reviews

Share learnings during IDT and align on prevention actions

IDT Leadership & Stakeholder Alignment

Participate onsite weekly at high‑volume SNFs

Lead goal‑oriented IDT discussions

Ensure follow‑through on agreed actions

Qualifications and Educational Experience:

5 years of nursing experience

Experience in case management, home health nursing, skilled nursing facility nursing.

Current nursing license – LPN or Registered Nurse with a BSN preferred

CPR/BLS certification

Comprehensive nursing assessment, problem identification, and care plan development

Implementation of clinical pathway knowledge

Motivational interviewing experience preferred

Relationship building with patients, families, facility staff, providers, and MSO/ACO partners

Documentation in EMR

Proficient in MS Office, especially Outlook, Word, Excel, and PowerPoint

Organized and resourceful self-starter

Excellent written, oral, interpersonal, and communication skills

Managed care and Utilization Review experience is a plus