52 Best transition coordinator Jobs in Paterson, New Jersey (April 2026)

Care Coordinator

2 days ago

Passaic

Job Description DISCLAIMER Job descriptions are not meant to be all-inclusive, and the job itself is subject to change. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. Summary The Care Coordinator serves as the main point of contact for facilities and physicians participating in the High Needs REACH program. This role blends care transition functions with provider consulting responsibilities to ensure patients experience seamless care coordination, facilities achieve measurable performance improvement, and providers are engaged with data-driven insights. The Care Coordinator will work closely with post-acute facilities, physicians, patients, and internal PBACO teams to reduce readmissions, improve quality, and strengthen participant satisfaction. This position requires strong communication skills, the ability to share and interpret data with stakeholders, and the clinical knowledge to support patients navigating their Medicare benefits. The role requires travel up to two times per month, including overnight stays, to meet with facilities and providers. Essential Duties and Responsibilities Care Coordination • Monitor ADTs (admission, discharge, transfer feeds) to identify outlier information that may impact patient outcomes., • Alert facilities or participating providers when relevant findings are identified., • Encourage communication between facilities and participating providers to support collaborative decision-making., • Serve as the primary liaison for High Needs REACH facilities and participating providers., • Conduct monthly facility performance review meetings, presenting data and opportunities for improvement with measurable action items., • Educate facility staff and providers on REACH program requirements, PBACO policies, and care coordination best practices., • Share facility- and provider-level data with stakeholders, highlighting opportunities for improvement., • Monitor and report on performance metrics such as readmissions, length of stay, transition timeliness, and patient satisfaction., • Document all patient, provider, and facility interactions in designated platforms with 100% compliance., • Collaborate with internal PBACO teams (Data Analytics, Clinical Action Team, Population Health) to align care coordination with organizational goals., • Identify facility-level trends or barriers impacting patient outcomes and escalate as needed. Care Coordination & Outcomes • ≥ 90% of patient transitions completed with documented PCP follow-up., • ≥ 85% patient satisfaction with outreach., • 100% of assigned facilities have monthly performance review meetings documented with measurable improvement goals., • ≥ 80% of participating facilities demonstrate improvement in at least one tracked metric (LOS, readmissions, or timeliness)., • ≥ 98% accuracy in documentation and reporting of patient transitions and facility metrics., • 100% of reports and meeting documentation completed within 48 hours of interaction., • Clinical Knowledge: Understanding of Medicare benefits, transitions of care, and post-acute continuum (SNF, HHA, rehab)., • Communication: Strong written/verbal skills for engaging patients, providers, and facility staff., • Data Interpretation & Analytics: Strong Excel and analytic skills; ability to synthesize and piece together data from multiple sources to create actionable opportunities tailored to different audiences., • Relationship Building: Develops trust with physicians, facility leaders, and patients., • Problem-Solving: Identifies barriers to care and develops creative, patient-centered solutions., • Education: Bachelor’s degree in Healthcare, Nursing, or Administration required; Master’s degree in a relevant subject preferred., • Experience: ≥ 2 years in SNF, HHA, care management, or provider relations., • Preferred: Prior ACO or value-based care experience, familiarity with High Needs populations., • Technical Skills: Strong Excel and data analytic skills required; proficiency in Microsoft Office; familiarity with care coordination platforms (e.g., CarePort, Epic, or similar)., • Combination of office-based work, facility visits, and occasional patient interaction., • May work at a computer for prolonged periods., • This is not a supervisory role.

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