Job Description

Coming home from the hospital or facing chronic health conditions can be challenging. It is our goal as a Transitions Care team member to support our patients and help prevent a return to the hospital. As a Bluegrass Transitions Care team member, you will work directly with patients and their caregivers, providing education and support in patient homes and community settings, to help patients better manage their chronic health conditions, and reduce unnecessary hospitalizations.

Schedule: PRN

Location: Jackson, Laurel, Whitley counties

Position Summary

The Transitions Care Coach provides individualized education and support to eligible patients across various care settings and environments. This role focuses on building trusting relationships with patients while guiding them toward improved health outcomes through education, encouragement, resource navigation, care coordination, and ongoing support. The Transitions Care Coach collaborates with patients to identify goals, overcome barriers, and promote self-management strategies that support optimal health outcomes and successful transitions of care.

Position Qualifications:

• Graduate of an accredited school of professional nursing (Registered Nurse).
• Current, unrestricted licensure as a Registered Nurse (RN) through the applicable State Board of Nursing.
• Minimum of 1–2 years of experience in home health, healthcare, care coordination, or a community-based healthcare organization preferred.
• Strong communication, interpersonal, and organizational skills with the ability to effectively engage with patients, families, caregivers, and healthcare professionals.
• Knowledge of medical terminology and healthcare processes.
• Demonstrated ability in patient education, coaching, and teaching principles.
• Ability to adapt and adjust approach based on the needs of diverse patient populations and care environments.
• Experience identifying problems, managing complex situations, and developing effective solutions.
• Strong customer service skills with the ability to work independently, prioritize responsibilities, and manage an assigned caseload.
• Ability to exercise sound judgment, discretion, and maintain confidentiality in accordance with HIPAA and organizational policies.
• Ability and willingness to conduct home visits in a variety of settings, including private residences, apartments, mobile homes, nursing facilities, hotels and condominiums, including environments where elevators may not be available.
• Ability to drive for extended periods of time without restriction or adverse effects.
• Excellent written and verbal communication skills with strong attention to detail.
• Proficiency with computer systems and electronic documentation platforms; computer access required for PRN team members and strong computer skills required for all team members.
• Ability to provide and receive constructive feedback in a professional manner.
• Commitment to compliance with Bluegrass Care Navigators (BCN) Employee Health, infectious disease prevention, and vaccination policies.
• Must be a licensed driver with an automobile in good working order, that is insured in accordance with state minimum requirements.

Bluegrass Care Navigators is committed to creating a diverse environment and complies with Equal Employment Opportunity and Title VI guidelines. Employment with Bluegrass Care Navigators, as well as our services, are available to all qualified individuals. We embrace and celebrate differences of persons of varying age, ethnicity, gender, disability, race, color, sex (including sex characteristics, intersex traits, pregnancy or related conditions), sexual orientation, gender identity, sex stereotypes, religion, national origin, political affiliation, socioeconomic and family status, geographic region, and other characteristics that make our employees unique.

It is the policy of Bluegrass Care Navigators to implement fair and effective personnel policies and to require all employees to serve the organization's mission and values.