Find your best fit.

ArchWell Health is a new, innovative healthcare provider devoted to improving the lives of our senior members. We deliver best-in-class care at comfortable, accessible neighborhood clinics where seniors can feel at home and become part of a vibrant, wellness-focused community. ArchWell Health members experience greater engagement, continuity of care, as well as the comfort of knowing they will be treated with respect by people who genuinely care about them, their families, and their communities.

Job Summary:

As a Transitions of Care Coordinator, you will play a vital role in ensuring members experience a smooth and supportive journey from hospital or skilled nursing facility back to their homes and coordination with the clinical care team. You will be the compassionate link between members, care teams, ArchWell Health’s Primary Care Providers, and hospital/SNF personnel helping to coordinate post discharge care preventing unnecessary hospital re-admissions and promote continuity of care. This is a hands-on, member facing position focused on building trusted, supportive relationships with seniors and their families –helping to reduce barriers to care and promote overall wellness.

This position is perfect for an experienced LPN or Medical Assistant who thrives on engaging with members and helping to eliminate obstacles to care. Strong communication skills and a passion for teamwork are essential as you work alongside the care management team and primary care team to improve overall healthcare outcomes for members.

Duties/Responsibilities:

· Patient Engagement & Outreach

o Proactively connect with members in assigned facilities to understand and support their healthcare needs.

o Conduct outreach (phone, in-person or virtual) within designated timeframes in advance of hospital or facility discharge.

o Build trust-based relationships with members that encourage adherence to care plans and foster long-term wellness.

o Support members and families with education around clinical conditions and care processes, including advanced care planning.

· Care Coordination

o Assist in scheduling primary care and specialty follow-up appointments.

o Build trust-based relationships with healthcare providers at assigned facilities to help coordinate care transitions from hospitals or skilled nursing

facilities, ensuring smooth communication across internal and external care teams.

o Obtain and share relevant hospital discharge information with clinical staff for appropriate follow-up care.

o Identify and address barriers to care such as transportation or medication accessParticipate in interdisciplinary team meetings to discuss patient needs and contribute to care planning.

o Assist Nurse Care Manager with member calls as appropriate.

o May assist with Care Calls as appropriate

Required Skills/Abilities:

· Must possess a high degree of emotional intelligence and integrity, driven and focused work ethic

· Ability to communicate effectively with diverse groups: members, families, hospital personnel, internal care teams and leadership

· Ability to work effectively with seniors and diverse populations including staff, providers, members, family members, insurance carriers, vendors and market leadership

· Strong communicator that is oriented to achieve best health care outcomes for the member and ArchWell Health

· Ability to work independently and collaboratively in a team setting

· Proficient skills in Microsoft Office Suite products including Word, PowerPoint, Outlook and Excel plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software

· Willingness to travel locally to hospitals and SNFs or Archwell centers daily

Education and Experience:

· High school diploma or equivalent (GED) required

· Graduation from an accredited LPN and/or RN program OR equivalent clinical training (e.g., foreign-trained physician, paramedic)

· LPNs must have an active, current license in the state of employment (preferred but not required)

· BLS certification for healthcare providers (required)

· Minimum of 5 year of experience as an LPN, preferably in a clinical setting.

· Experience working with seniors is strongly preferred

· Strong emotional intelligence, communication skills, and a team-focused mindset

· Comfortable working with diverse populations and collaborating across various roles

Proficiency in Microsoft Office (Word, Outlook, Excel) and electronic health records (EHR) systems