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Transition of Care Coordinator

Community Health Group Chula Vista, CA
  • Posted: over a month ago
  • Full-Time
  • Benefits: Vision, Medical, Life Insurance, 401k, Dental

Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for: Transition of Care Coordinator


Will identify and coordinate resources to assist members in the transition back to living in the community and to live as independently as possible. Will also visit CHG members in their home, Assisted Living Facilities, and/or Long Term Care Facilities.


  • Will work in close collaboration with CHG’s Interdisciplinary Care Team and contracted physician groups who conduct assessments to establish care needs.

  • Will visit members in their homes and/or treatment facilities; approximately 50% of time devoted to work outside of the office.

  • Work with identified members to assess their care needs.

  • Interview all prospective members who have indicated interest in returning to the community.

  • Make referrals to available resources in the community.

  • Develop strong linkages with community-based health care providers to promote quality and availability of services.

  • Facilitate, promote, and advocate for the member's ongoing self-sufficiency and independence.

  • Educate members within a nursing facility on home and community-based alternatives and assess the member's potential for and interest in transitioning from the facility to community.

  • Facilitate and execute specific interventions to ensure the member's health, safety, and welfare.

  • Organize, integrate, and modify resources needed to establish the plan of care for each member.

  • Provide resource information and education regarding the community-based needs of our members.

  • Be available to members, family members/informal supports and legal guardians to answer questions.

  • Support a member's right to be the decision-maker regarding life goals, activities, services and providers.

  • Bachelor’s degree in a health related field (i.e., social work, social welfare, psychology, or health education).


  • Minimum 3 years’ experience in managed care experience preferred.

  • Ability to communicate effectively both in person and in writing.

  • Bilingual (English/Spanish preferred; or English/Vietnamese, English/Arabic, English/Tagalog).

  • Knowledge of community health and social service agencies and additional community resources.

  • Exceptional customer services, communication and interpersonal skills with the ability to quickly build rapport.

  • Ability to work with minimal supervision within the role and scope.

  • Ability to use a variety of electronic information applications/software programs including electronic medical records.

  • Intermediate to Advanced computer skills and experience with Microsoft Word, Outlook, and Excel.

  • Reliable transportation with current California driver’s license and proof of auto insurance.

  • Previous care coordination experience to Medi-Cal (Medicaid) and/or Medicare recipients receiving long-term care and/or home and community based services.

  • Previous managed care and/or long-term care experience.

  • Experience working with the geriatric population.

  • Experience with health promotion, coaching and wellness.

Community Health Group

Community Health Group, a locally based non-profit health plan, we are committed to serving the underserved populations in our market. We have consistently been recognized for our outstanding customer service from staff, community, providers, member and employers. We were recently recognized as one of the “Top Workplaces in San Diego”. We are accredited by NCQA and have been recognized for our quality initiatives especially as it relates to HEDIS scores. Equal Opportunity Employer.


Chula Vista, CA

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