Registered Nurse (RN) Transition Care Coordinator

Charlottesville, VA
Feb 20, 2019
Apr 12, 2019
Full Time

Optima Health Community Care is hiring a committed Registered Nurse for the role of Transition Care Coordinator to assist and service our valued members with complex discharge planning needs associated with their transitions to and from various residential settings.

The selected candidate will have:

•Demonstrated experience with discharge planning and critical nursing assessment skills.

•Minimum of 3 years of Registered Nurse (RN) experience, case management preferred.

•Ability to adequately function both remotely from home and field-based in the community.

•Superb customer service, planning, and communic

ation skills.

•Responsibility for territory within the entire Charlottesville, VA region and surrounding western area.

•Knowledge of Medicaid services and programs.

•Minimum BSN Nursing Degree.

•Permanent Virginia residency.

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Division Highlights:

Optima Health Community Care is a Commonwealth Coordinated Care Plus (CCC Plus) Medicaid plan for many older people and those with disabilities. CCC Plus is a Medicaid managed care program through the Virginia Department of Medical Assistance Services (DMAS).

With Optima Health Community Care, members benefit from an individualized, fully-integrated program with a state-wide network of providers. As an Optima Health Community employee, you will join a care team committed to providing customized and personalized support and services in the community that our members can count on. Optima Health is a service of Sentara Healthcare, so joining Optima is joining the Sentara Healthcare family.

Sentara Benefits:

Sentara employees strive to make our communities healthier places to live. We’re setting the standard for medical excellence within a vibrant, creative, and highly productive workplace.

Join our team, where we are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, growth!

BLS (if in a clinical setting). For Integrated Care Management departments, specialty certification required within one year of eligibility (ACM, CCM, CCCTM or RN-BC). For other service lines, certification based on specialty area required within one year of eligibility. 3 years Case Management experience preferred.

Keyword: RN, Registered Nurse, discharge, transitions, LTSS, managed care

Equal Opportunity Employer
Sentara maintains a drug-free workplace


The Transition of Care Coordinator is responsible for managing and supporting all transitional care and post-acute services in a defined geographic region. Care transitions include individuals transitioning from Nursing Facilities, hospitals, inpatient rehabilitation, or other institutional settings into the community, and individuals who desire to remain in their community setting. The Transition of Care Coordinator works closely with the Care Coordinator and the Interdisciplinary Care Team (ICT) to facilitate safe and effective workflow and processes, and plan, coordinate, monitor and evaluate options to meet the individual¿s needs. Will develop and oversee the transition plan insuring a smooth handoff to the Care Coordination Manager upon completion of the transition process.


Education Level
RN-Bachelor's Level Degree - NURSING

Required: Nursing - 3 years

Preferred: None, unless noted in the "Other" section below

Required: Registered Nurse

Preferred: Basic Life Support


Preferred: None, unless noted in the "Other" section below

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