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Transitional Care Specialist - Fulltime

Lorian Health
3 hours ago
Full-time
On-site
San Diego, California, United States
Bachelor's, Master's

For over 20 years, Lorian Health has been a trusted leader in home health care, dedicated to enhancing patients’ quality of life and supporting their independence.

The Transitional Care Specialist is a corporate-level clinical operations leader responsible for designing, implementing, and overseeing Lorian’s Transitional Care across all Home Health branches. This full-time role combines field-based clinical presence, including home visits and bedside visits in hospitals, skilled nursing facilities, and other care settings, with strategic oversight, performance monitoring, and cross-functional leadership to improve outcomes for clinically complex, high-risk patients and support timely transitions across the continuum of care.

Location: 9655 Granite Ridge Dr #500 San Diego, CA 92123

Responsibilities 

  • Conduct home visits and bedside visits as needed to assess complex cases, support patient and family education, reinforce clinical planning, and model best practices for branch teams.
  • Travel regularly to branch locations, patient homes, hospitals, skilled nursing facilities, and other care settings in support of the program’s clinical and operational goals.
  • Maintain a visible field presence to evaluate workflow effectiveness, identify barriers, and coach teams in real time.
  • Collaborate with MSWs, RNs, LVNs, therapists, hospice teams, and clinical managers to improve patient transitions and goals-of-care planning.
  • Support regular MSW rounds or related psychosocial review structures for complex transitional care cases.
  • Ensure all program-related actions, communication, and interventions are documented accurately and timely in HCHB or other designated systems to support compliance and audit readiness.
  • Track and evaluate program outcomes such as hospitalization avoidance, post-discharge retention, and hospice referral activity.
  • Ability to access patient homes, hospitals, branch offices, and other clinical environments as needed.
  • Ability to use standard office and clinical technology for documentation, communication, and reporting.

Qualifications

  • Minimum of 1 year of experience in home health or hospice
  • Current, active, and unrestricted clinical licensure in the State of California, as applicable to role requirements.
  • Bachelor’s degree in Nursing, Social Work, healthcare administration, or related field preferred.
  • Strong understanding of transitional care workflows, high-risk patient management, hospitalization reduction strategies, and hospice transitions.
  • Advanced knowledge of home health clinical operations, interdisciplinary team coordination, and compliant documentation practices.
  • Ability to analyze workflow performance, identify gaps, and implement improvements across diverse branch environments.
  • Strong communication, facilitation, and relationship-building skills with the ability to influence teams across the organization.
  • Proficiency with EMR and reporting systems, including HCHB and other tracking tools used to monitor patient status, hospitalizations, and branch performance.

Salary ranges from $95-$105,000 commensurate with experience