Clinical Transitions Coordinator

Company: M&H Housecalls
Location: Cape Coral
Posted on: February 16, 2026

Job Description:

Job Description Job Description Role Purpose 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 – 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

Keywords: M&H Housecalls, North Fort Myers , Clinical Transitions Coordinator, Healthcare , Cape Coral, Florida