Post Acute Care Coordinator at Palm Beach Accountable Care Organization

Are you passionate about improving patient outcomes and ensuring smooth care transitions? Join our Network Development Team as a Post Acute Transition Coordinator — a vital role that bridges hospitals, patients, and post-acute providers to deliver seamless, compassionate care during one of the most critical stages of recovery.

As a trusted care connector, you’ll coordinate the journey from hospital to home or post-acute care facilities, ensuring each patient receives the support, resources, and follow-up they need to thrive. Your work will help reduce readmissions, strengthen partnerships, and elevate the quality of care across our network.

• Coordinate seamless care transitions from hospital discharge to skilled nursing, rehab, or home-based services.




• Develop individualized care plans by collaborating with physicians, nurses, social workers, and families.




• Communicate across settings to ensure continuity, timely documentation, and exceptional patient experiences.




• Monitor progress post-discharge and proactively address barriers to care or readmission risks.




• Promote best practices and compliance with all care coordination and regulatory standards.




• Serve as a trusted advocate for patients and families navigating complex healthcare systems.

Minimum Qualifications

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field




• 2+ years of experience in care coordination, case management, or discharge planning within a healthcare environment




• Strong understanding of post-acute care services and patient discharge processes




• Excellent communication, collaboration, and organizational skills




• Proficiency with EHR systems and care management software

Preferred Qualifications

• Registered Nurse (RN) license or Certified Case Manager (CCM) credential




• Experience supporting diverse or complex patient populations




• Familiarity with Medicare, Medicaid, and insurance authorization processes




• Training in motivational interviewing or patient advocacy




• Advanced certifications in care coordination or transitions of care

• Skilled at juggling multiple patient cases while keeping care quality front and center




• Analytical thinker who can identify risks and implement effective care plans




• Relationship-builder who fosters trust and cooperation across multidisciplinary teams




• Confident navigating healthcare regulations and insurance systems




• Tech-savvy professional with proficiency in MS Office and healthcare data tools (MS Project, Smartsheet, Asana, etc.)

• Make a measurable impact on patients’ recovery journeys and long-term well-being




• Collaborate with mission-driven professionals who share your passion for high-quality care




• Grow your career through exposure to diverse healthcare systems and innovative care coordination practices




• Enjoy flexibility across regional roles (Southwest, Central, Northwest) with a supportive leadership team that values balance, integrity, and collaboration

Physical Demands:
This position requires periods of sitting, standing, and working at a computer. Occasional lifting (up to 10 lbs) may be needed.

Equal Opportunity Employer
We celebrate diversity and are committed to creating an inclusive environment for all employees.

Ready to make a difference in how patients experience post-acute care?
Apply today and help redefine what successful care transitions look like.