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Transitional Care Jobs in Tennessee (NOW HIRING)

Care Coordinator- Knoxville

Knoxville, TN ยท On-site

$45K - $55K/yr

Care Coordinator Segue Health, a faith based medical practice, is looking for a Care Coordinator to work in a Knoxville, TN area hospital coordinating post discharge transitional care management.

Care Coordinator- Knoxville

Knoxville, TN ยท On-site

$45K - $55K/yr

Segue Health, a faith based medical practice, is looking for a Care Coordinator to work in a Knoxville, TN area hospital coordinating post discharge transitional care management. This position ...

Segue Health, a faith based medical practice, is looking for a Care Coordinator to work in a Knoxville, TN area hospital coordinating post discharge transitional care management. This position ...

Occupational Therapist

Maryville, TN

$35 - $46.25/hr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

OCCUPATIONAL THERAPIST - FULL TIME FOOTHILLS TRANSITIONAL CARE AND REHABILITATION - MARYVILLE, TN Join our team and start making a difference! Flexible schedule with work-life balance Call or text ...

Occupational Therapist

Maryville, TN ยท On-site

$35 - $46.25/hr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

OCCUPATIONAL THERAPIST - FULL TIME FOOTHILLS TRANSITIONAL CARE AND REHABILITATION - MARYVILLE, TN Join our team and start making a difference! Flexible schedule with work-life balance Call or text ...

Occupational Therapist

Maryville, TN ยท On-site

$35 - $46.25/hr

  • Medical

  • Dental

  • Vision

  • Retirement

  • PTO

OCCUPATIONAL THERAPIST - FULL TIME FOOTHILLS TRANSITIONAL CARE AND REHABILITATION - MARYVILLE, TN Join our team and start making a difference! Flexible schedule with work-life balance Call or text ...

For patients that are unable to come to the office-in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care ...

For patients that are unable to come to the office-in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care ...

For patients that are unable to come to the office-in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care ...

Showing results 41-60

Transitional Care information

What is transitional care?

Transitional care refers to a set of coordinated healthcare services that help patients move smoothly from one care setting to another, such as from a hospital to their home or a rehabilitation facility. The goal is to ensure continuity of care and prevent complications, such as hospital readmissions. Transitional care typically involves communication among healthcare providers, medication management, follow-up appointments, and patient education. It is especially important for individuals with complex or chronic conditions who are at higher risk during care transitions.

What are the key skills and qualifications needed to thrive in transitional care?

To excel in Transitional Care, professionals typically require a background in nursing, social work, or case management, along with knowledge of care coordination and discharge planning. Familiarity with electronic health records (EHRs), care management software, and possibly certification like CCM (Certified Case Manager) is often beneficial. Strong communication, empathy, and problem-solving abilities are crucial for effectively supporting patients and collaborating with healthcare teams. These skills ensure smooth care transitions, prevent hospital readmissions, and enhance patient outcomes during vulnerable periods.

How does a transitional care professional typically collaborate with other healthcare teams to ensure smooth patient transitions?

Transitional Care professionals work closely with physicians, nurses, social workers, and other allied health staff to coordinate patient care as individuals move between different healthcare settings, such as from hospital to home. This collaboration often involves regular interdisciplinary meetings, thorough documentation, and clear communication to ensure continuity of care and reduce readmission risks. Effective teamwork is essential, as Transitional Care professionals often serve as liaisons, advocating for patient needs and ensuring all members are updated on care plans. Building strong relationships across departments is a key part of the role, helping to identify and resolve potential barriers to successful transitions.

What are the most commonly searched types of Transitional Care jobs in Tennessee?

The most popular types of Transitional Care jobs in Tennessee are:

Infographic showing various Transitional Care job openings in Tennessee as of August 2026, with employment types broken down into 75% Full Time, and 25% Part Time. Highlights an 100% In-person job distribution.

Advertised Certified MDS Coordinator, Registered Nurse, Transitional Care

Covenant Health (Tennessee)

Knoxville, TN โ€ข On-site

$35.50 - $43/hr

Other

Posted 5 days ago


Job description

Certified Mds Coordinator, Registered Nurse, Transitional Care

PRN/OCC, Variable Hours, Day Shift

Fort Sanders Regional Overview:

Fort Sanders Regional Medical Center is a 444-bed hospital recognized for pairing clinical expertise with advanced medical technology to deliver exceptional care. As a Joint Commission Comprehensive Stroke Center, we provide leading-edge treatment for stroke recovery. Our facility also offers specialized services in bariatric surgery, robotic surgery, minimally invasive spine procedures, and advanced orthopedic care.

Fort Sanders Regional is part of Covenant Health, East Tennessee's largest nonprofit health system and a Becker's "Top 150 Places to Work in Healthcare." Covenant Health includes nine hospitals and nearly 150 service locations, offering employees a comprehensive benefits package with tuition reimbursement, student loan assistance, certification bonuses, and leadership development programs.

Position Summary:

Assesses, plans, monitors and evaluates options and services to meet an individual's health needs through communication and the coordination of available resources. Enhances service quality and assists in the delivery of Attends seminars on LTC Perspective Payment System and updates on federal and state regulations and disseminates information to staff.

Responsibilities
  • Will schedule the ARD's (Assessment Reference Date) for Payment Assessments with the Rehab Director or designee daily, weekly, and as needed in a manner that accurately captures the RUG (Resource Utilization Group) category.
  • Will provide a schedule of ARD's and Assessment types weekly and as needed to the IDT in order to facilitate the timely completion of MDS sections and CAA's (Care Area Assessments) by each discipline.
  • Is expected to use the RAI Manual as a resource during the assessment coding process.
  • Will coordinate the completion of MDS sections according to facility assignments.
  • Will communicate to members of the IDT as needed based on timeliness of completion. The MDS Coordinator is expected to report any issues with timely completion to the Administrator immediately.
  • Will facilitate with the IDT members, the completion of assessments and corresponding due dates for Z0400A-L, Z0500B, V0200B2 and V0200C2 according to the RAI Manual; reference Chapter 2, Section 2.6.
  • Will ensure the transmission of Admission and Discharge Assessment and PPS within 14 days of the completion date in Z0500B; reference Chapter 5, Section 5.2.
  • Will ensure the transmission of Comprehensive assessments within 14 days of the Care Plan Completion Date (V0200C2).
  • Will confirm the transmission file and review the printed initial and final validation report.
  • Will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepted validation report is received.
  • Will also address non-fatal errors using the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System MDS 3.0 Provider User's Guide. Reference RAI Manual Chapter 5, Section 5.5.
  • Will maintain validation reports in a transmittal notebook to be organized by month.
  • Will facilitate the completion and updating of resident care plans within the MDS Department and the IDT to reflect the resident's most current needs.
  • Will identify residents in need of a Significant Change in Status Assessment based on criteria in the RAI Manual Chapter 2, Section 2.6.
  • Will participate the interdisciplinary care plan team meeting weekly and as needed.
  • Will participate in facility staff education as it relates to the RAI process, and the coordination of obtaining accurate documentation from direct care staff.
  • Will notify the facility Director of Nursing (DON) and/or Administrator of risk areas when coded on the MDS.
  • Will compile data reports based on MDS data as requested by the Administrator or DON.
  • Will utilize the facility's software program and computer system to comply with federal requirements for completion and encoding.
  • Attends seminars on LTC Perspective Payment System and updates on federal and state regulations and disseminates information to staff.
  • Serves as clinical and regulatory resource for all staff.
  • Participates in mock surveys in preparation for state and the federal surveys
  • Reviews medical records regularly for adherence to care plan. Investigates variances from plan and adjusts plan based upon assessment.
  • Verifies billing office information to assure consistent billing of RUG categories.
  • Tracks RUG days monthly and reports to Administration on reimbursement status.
  • Functions as Infection Control Nurse for TCU. Collects, monitors and disseminates data relating to infection control indicators. Collaborates with hospital Infection Control contact on unit specific and hospital-wide issues.
  • Provides education on infection control process and regulations to staff.
  • Assists with orientation of new hires regarding HCFA regulations of LTC/PPS.
  • Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
  • Assists in maintaining a safe environment for all residents, which may include reporting to appropriate managerial staff equipment that is out of order, suspicion of resident abuse, mistreatment, neglect and reporting of suspicion of criminal activities.
  • Complete nursing duties when necessary as specified in nursing policies.
Qualifications

Minimum Education: None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.

Minimum Experience: Two (2) to five (5) years clinical practice is required. Excellent communication skills, leadership skills; ability to accept and incorporate feedback; problem solving and priority setting skills.

Licensure Requirement: Current RN license, RAC-C (Resident Assessment Coordinator-Credentialed) certification through AANAC required within 90 days of hire into position.