• Regional Transition Care Coordinator

    Job Locations US-VA-Charlottesville
    Job ID
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
    If this sounds like you, read on!


    Under the supervision of the Manager, the Regional Transition Care Coordinator is responsible for managing members who undergo transitions of the following:

    1. Hospitals (acute discharge) to:
      1. Nursing facility (skilled or custodial)
      2. Community with HCBS waiver
      3. Community without HCBS waiver
    2. Hospitals (psychiatric) discharge to:
      1. Nursing facility (skilled or custodial)
      2. Community with HCBS waiver
      3. Community without HCBS waiver
      4. Residential Treatment Facility
    3. HCBS waiver to:
      1. Hospital (acute or psychiatric)
      2. Nursing facility (skilled or custodial)
      3. Residential Treatment Facility
    4. Community without HCBS waiver to:
      1. Hospital (acute or psychiatric)
      2. Nursing facility (skilled or custodial)
      3. Community with HCBS waiver
      4. Residential Treatment Facility
    5. Long-term Institution transition to:
      1. Community with HCBS waiver
      2. Hospital and back to Nursing Facility 



    Participates in discharge planning for Members transitioning from acute institutional settings to lower levels of care, including Long Stay Hospitals, Nursing Facilities, and the community

    • Provides support to care coordinators to maintain Members in the community in lieu of transitioning to institutional settings, as needed.
    • Serves on the ICT for all members who are in transition
    • Facilitates communication and coordination between members of the health care team
    • Provides referrals for brief and immediate crisis intervention (i.e. Adult Protective Services).
    • Educates the member, the family or caregiver, and members of the health care team about treatment options, community resources, insurance benefits, psychosocial concerns, care management , etc., so that timely and informed decisions can be made.
    • Empowers the member to problem solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes
    • Strives to promote member self-advocacy and self-determination
    • Acts as an advocate for a member’s health care needs
    • Practices in accordance with applicable local, state and federal laws which govern confidentiality and medical information privacy regulations (HIPAA)



    • Bachelor degree in Health or Human Services 
    • Registered Nurse licensed to practice in the Commonwealth of Virginia (Bachelor preferred) OR;
    • Licensed Practical Nurse in the Commonwealth of Virginia
    • Certified Case Manager preferred


    • Excellent oral and written communication skills
    • PC literate with working knowledge of Microsoft Office and various computer software programs
    • Working knowledge of community resource options, and experience in making appropriate referrals
    • Strong decision making skills and ability to handle multiple priorities
    • Knowledge of case management and transitions/discharge planning
    • Knowledge of home and community based service waivers needed
    • Some local travel may be necessary 


    • Must have valid Driver's license with positive points on DMV record.
    • Willing and able to conform to pre-employment background check


    • Physical health sufficient to meet the ergonomic standards and demands of the position

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


    Our mission is to inspire healthy living within the communities we serve!



    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed

    Need help finding the right job?

    We can recommend jobs specifically for you! Click here to get started.