Care Coordinator / Nurse Navigator (LPN)

Post-Acute & Hospital Transitions Specialist

Position Summary

The Care Coordinator / Nurse Navigator (LPN) supports safe, efficient transitions between skilled nursing facilities (SNFs), nursing homes, and hospitals by coordinating care plans, improving communication between providers, and reducing avoidable readmissions. This role serves as a clinical liaison across care settings and helps ensure continuity, compliance, and patient-centered outcomes during transitions of care.

This position requires an experienced LPN with direct SNF/nursing home background and strong working knowledge of post-acute workflows, discharge planning, and regulatory expectations.

Key Responsibilities

Transition-of-Care Coordination

• Coordinate patient transfers between SNFs, hospitals, and post-acute providers
• Perform admission and readmission transition reviews
• Ensure completion and accuracy of transfer documentation
• Support safe discharge planning from hospital to facility
• Assist with high-risk patient tracking and follow-up

Clinical Communication & Liaison Support

• Serve as liaison between:
  
  • facility nursing teams
  • hospital case management
  • attending providers
  • medical directors
  • therapy teams
• Communicate changes in condition to appropriate stakeholders
• Support implementation of provider care plans across settings

Readmission Prevention

• Identify patients at high risk for hospitalization
• Monitor early warning indicators:
  
  • falls
  • infections
  • medication changes
  • decline in functional status
  • abnormal vitals/labs
• Coordinate early intervention strategies with providers and facility teams

Documentation & Compliance

• Review transfer packets for completeness and accuracy
• Ensure continuity of:
  
  • medication reconciliation
  • code status
  • advance directives
  • diagnoses and problem lists
• Support regulatory compliance with CMS transition-of-care expectations

Facility Collaboration

• Participate in:
  
  • IDT meetings
  • QAPI initiatives
  • readmission review processes
• Assist facilities in improving transition workflows
• Support communication with corporate clinical leadership when needed

Patient & Family Support

• Provide education regarding transition expectations
• Assist families navigating movement between care settings
• Reinforce discharge instructions and follow-up plans