Transitional Care Coordinator

Job Locations US-GA-Sandy Springs
Active/Full Time/Regular

Job Summary

Why WellBe?

WellBe’s Culture is Welcoming

  • Be part of something important:
    • Be part of pioneering a new way of healthcare that is revolutionizing the industry. 
    • A patient-focused environment that ensures patients can live a fulfilling life whatever their health level is. Our focus is to give our patients more good days.
  • Give yourself incredible opportunities:
    • Growth and development opportunities across expanding markets in the company and celebrate success on a global scale.
    • Training in the WellBe model and team-based care. Full in-person orientation, vision, mission, and values introduction, and instilling cultural ideals. Respect and trust for how you work and how you make a difference.
    • Work as part of a collaborative team with a strong team culture.
    • You own your role, contribute to the team, and feel the enormous impact on lives.
    • Leadership that listens, trusts, empowers, and supports.
    • Empowerment and ownership for solving problems that arise and doing the right thing in each interaction.
    • Pioneering a new way of healthcare that is revolutionizing industry.  

What we offer: 

  • Full-time permanent, work seeing patients in their home, traveling around to other home locations.  Work during the daytime, flexible schedule, and on-call rotation.
  • Rich and competitive total rewards package including health benefits, dental, vision, life insurance, dependent care reimbursement, STD/LTD, 401k match with immediate vesting, paid time off / floating holidays, commuter/transportation (mileage) reimbursement, and educational reimbursement.
  • The opportunity to work with a progressive company, who is making a difference each day with every patient. 

About the Position:

This position is responsible for developing relationships with Emergency Department and Care Management staff in hospitals and Skilled Nursing facilities (SNF’s) This candidate will work collaboratively with multiple facilities to arrange and schedule transition of care visits.  The position will help educate patients about WellBe's program, close gaps in communication between patients and care management and nursing staff and coordinate smooth transitions post-discharge. This candidate will also be responsible for care coordination needs and supporting WellBe clinicians with operational and clinical tasks.

Job Description

Job Description

  • Practices the WellBe mission
    • To help our patients lead healthier, meaningful lives by delivering the most Complete Care. 
  • Patient Communication
    • Engages in telephonic conversations with eligible patients and their families, providing a thorough explanation of the WellBe program and its comprehensive care model, aiming to obtain their consent to participate.
  • Admissions Tracking
    • Communicate with hospital/discharge planners, notify the patient of WellBe's awareness of their hospitalization, and continuously track admissions.
    • Identify barriers to discharge and care coordination needs by verifying information through HIE/hospital EMR and direct contact.
  • Medical Record Retrieval and Uploading
    • Retrieve and upload medical records for all admission types (ED, OBS, IP, Inpatient rehab, SNF).
  • Data Management
    • Manage daily hospital census.
    • Review all new alerts and update POS, Dispo, discharge date, etc., with correct/updated information.
    • Escalate examples/concerns of data discrepancies to the data team for continuous improvement efforts.
  • Post-Discharge Tracking and Scheduling
    • Make call attempts within 48-72 hours, following a structured script to assess general health status, medications, discharge instructions, SDOH (Social Determinants of Health) screening, and scheduling.
    • Uses EHR system to manage patient data, makes updates based on communication from hospital and SNF partners, and communicates relevant information to WellBe Clinician.
  • Discharges to SNF (Skilled Nursing Facility)
    • Admission verification to SNF, obtain estimated LOS, and working collaboratively with SNF/discharge planners.
  • Coordination with APPs and CMDs
    • Escalate patient concerns, including barriers to discharge or post-discharge needs, to the APP (Advanced Practice Provider) or CMD (Care Management Director).
    • Regularly huddle with Liaisons and coordinate on high-priority facilities and patients
    • Participates in weekly Interdisciplinary Team (IDT) meetings.
  • Other duties as required by the manager to accomplish team’s objectives/goals

Job Requirements

Must Haves:

Educational/ Experience Requirements:

  • High school graduate or GED 
  • Minimum 3+ years of experience working in case management with discharge planning (Health unit secretary or Health unit coordinator) and/or referral coordinator.
  • Managed Care experience preferred

Required Skills and Abilities:

  • Attention to detail
    • Candidates should have a meticulous approach to their work, ensuring accuracy and precision in tasks such as data entry, record keeping, and following established protocols.
  • EMR documentation experience preferred
    • Proficiency in using EMR software (and Excel Spreadsheets) allows for efficient and accurate documentation of patient information, treatment plans, and medical histories.
  • Strong customer centric focus/service skills
    • The candidate should possess exceptional customer service skills with a focus on the patient experience. They should be empathetic, compassionate, and able to effectively communicate with patients and their families.
  • High level of professionalism 
    • Adhering to ethical standards, maintaining patient confidentiality, and demonstrating integrity in their interactions with colleagues, patients, and their families. 

Travel requirementsTravel may be required up 0% locally.


Work Conditions:

Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. Ability to stand for extended periods. Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills/Visual acuity


WellBe Senior Medical is an equal opportunity employer. We embrace diversity, inclusion, and equity and encourage all interested readers to apply at

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change, or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.


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