Remote Transitions of Care Coordinator

Job Overview

Virelia Health connects healthcare professionals with opportunities across transitions of care, post-discharge follow-up, and readmission prevention.

We are seeking qualified Transitions of Care Coordinators for remote opportunities supporting health plans, accountable care organizations (ACOs), value-based care groups, hospitals, and care management programs.

A Remote Transitions of Care Coordinator supports members after hospitalization or emergency department visits — post-discharge follow-up, medication reconciliation support, follow-up appointment coordination, and care transition support. Working alongside the member's care team, the transitions coordinator helps members understand their discharge instructions, get to their follow-up appointments, and avoid unnecessary readmissions.

This is a transitions of care role. It's distinct from ongoing care management — transitions of care focuses on the critical window immediately after a hospital or ED visit rather than ongoing care planning. It's also distinct from discharge planning — the transitions coordinator works on the post-discharge side, supporting the member after they leave the facility. The role combines post-discharge assessment, medication reconciliation support, follow-up coordination, and readmission prevention.

This position is well-suited to an RN, LPN/LVN, or care coordination professional with transitions of care, post-discharge follow-up, or readmission prevention experience who enjoys supporting members through the vulnerable post-discharge period.

The specific transitions program, member population, technology platform, and scope of responsibilities will depend on the employer and assignment.

This opportunity may be suitable for professionals searching for remote transitions of care coordinator jobs, post-discharge follow-up coordinator, work-from-home readmission prevention coordinator, remote transitional care coordinator, or remote discharge follow-up nurse roles.

What You'll Do

As a Remote Transitions of Care Coordinator, you may support members across the full post-discharge transition.

• Complete post-discharge outreach calls within the program's required timeframe (typically 24–72 hours).
• Review discharge instructions with the member and confirm understanding.
• Support medication reconciliation — review discharge medications, identify discrepancies, and connect members with pharmacists or providers as needed.
• Confirm follow-up appointments are scheduled and support members in getting to them.
• Assess member needs post-discharge — clinical, functional, and social.
• Screen for red flags and warning signs that may indicate deterioration.
• Educate members on warning signs and when to seek care.
• Support members in understanding their discharge diagnosis and care plan.
• Coordinate with home health, DME, and community resources as needed.
• Identify social barriers to recovery — transportation, food, housing — and connect members with resources.
• Document all post-discharge contacts accurately in the transitions platform.
• Coordinate with the member's care team — PCP, specialists, home health, and care manager.
• Escalate clinical concerns, medication issues, or social barriers to the appropriate team.
• Follow emergency escalation protocols for members reporting acute symptoms.
• Participate in interdisciplinary care team meetings and transition case reviews.
• Protect member privacy and maintain HIPAA compliance across all transitions activities.

Transitions of Care Focus

Transitions of care programs support members through the vulnerable period immediately after a hospital or ED visit — when the risk of readmission, medication errors, and missed follow-up is highest. Transitions coordinators are the safety net that helps members transition home successfully.

Depending on the program, transitions of care may focus on:

The transitions coordinator's role is to support members through the post-discharge period — reviewing discharge instructions, supporting medication reconciliation, confirming follow-up, screening for red flags, and documenting all contacts. Clinical decisions, medication changes, and diagnostic decisions belong to the member's treating providers; the transitions coordinator supports the member's recovery and coordinates with the care team.

This structure keeps the role focused on post-discharge assessment, coordination, documentation, and appropriate escalation.

Readmission Prevention & Member Support

Transitions of care success depends on catching problems early — screening for red flags, supporting medication understanding, and ensuring members get to their follow-up appointments.

You may support readmission prevention by:

• Reviewing discharge instructions and confirming member understanding.
• Supporting medication reconciliation — identifying discrepancies and connecting members with resources.
• Confirming follow-up appointments are scheduled and supporting members in getting there.
• Screening for warning signs — worsening symptoms, medication issues, and functional decline.
• Educating members on warning signs and when to seek care.
• Identifying social barriers — transportation, food, housing, and caregiver support — and connecting members with resources.
• Coordinating with home health, DME, and community resources.
• Documenting all contacts and escalating concerns promptly.
• Following up consistently through the 7-day and 30-day windows.

Clear communication, member empathy, and rigorous follow-up are essential — transitions coordinators are the safety net that helps members recover successfully at home.

Transitions of Care Workflow

A Remote Transitions of Care Coordinator may follow a structured workflow across each member's transition.

Depending on the employer's protocols, you may:

Required Qualifications

• Active RN, LPN/LVN, or relevant clinical credential in good standing in the state(s) required by the employer, or comparable care coordination experience.
• Previous experience in transitions of care, post-discharge follow-up, care coordination, or readmission prevention.
• Strong assessment, member engagement, and documentation skills.
• Comfortable with care management platforms and virtual member outreach.
• Strong documentation and time-management skills.
• Ability to recognize situations requiring clinical escalation.
• Ability to work independently in a remote environment.
• Ability to maintain confidentiality and HIPAA compliance.
• Reliable internet and a private workspace suitable for confidential member conversations.

Preferred Qualifications

Experience or certification in any of the following may be beneficial:

Skills & Competencies

Clinical Transitions Skills

Member Engagement & Communication

Digital Health & Technology

A Typical Day

A typical day may begin by reviewing your discharge notification list — checking which members were recently discharged and are due for outreach within the required timeframe.

You'll call members who have recently been discharged — reviewing discharge instructions, supporting medication reconciliation, confirming follow-up appointments, and screening for red flags.

Between calls, you'll coordinate with home health, DME, and community resources, document each contact accurately, and follow up on members who haven't been reached.

You'll escalate members with clinical concerns, medication issues, or social barriers to the appropriate team, and follow up through the 7-day and 30-day windows.

The role combines post-discharge outreach, medication reconciliation support, follow-up coordination, red flag screening, documentation, and appropriate escalation.

Unlike ongoing care management, which builds long-term member relationships, transitions of care focuses on the critical post-discharge window — you're the safety net that helps members recover successfully at home.

Remote Work Environment

This position is designed for remote transitions of care coordination.

Depending on the employer, you may work with:

Candidates should have a stable internet connection, a private workspace suitable for confidential member conversations, and comfort with multiple care management and clinical systems.

Licensure & State Eligibility

Remote transitions of care coordinator roles are currently in highest demand in states with strong value-based care adoption, health plan transitions programs, and hospital readmission reduction initiatives:

Top-demand states: California, Texas, Florida, New York, Pennsylvania, Ohio, Illinois, Michigan, Georgia, North Carolina, Arizona, Colorado.

Strong secondary markets: Alabama, Connecticut, Indiana, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Missouri, New Jersey, Tennessee, Virginia, Washington, Wisconsin.

Licensure requirements vary by employer. Some transitions of care roles require an active RN or LPN/LVN license in the state(s) where members reside. Others accept relevant care coordination experience without a clinical license. Always confirm the specific requirements with the employer before applying.

Want to know which states accept remote healthcare roles? Read our remote healthcare licensure guide.

Compensation & Benefits

This position offers $25–$42 per hour, based on licensure (RN vs. LPN vs. non-clinical), experience, geographic location, credentials, and assignment requirements. Remote transitions of care roles typically offer predictable weekday schedules with structured outreach cadences.

Benefits are assignment-specific and may vary depending on whether the opportunity is full-time, part-time, contract, or direct hire. Depending on the employer, benefits may include:

Why Consider Remote Transitions of Care Coordination?

Transitions of care is a growing area of healthcare — driven by value-based care expansion, health plan investment in readmission reduction, and the recognition that the post-discharge window is critical to member outcomes.

Many coordinators find transitions of care roles appealing because they offer:

• Meaningful member impact — you're the safety net that helps members recover successfully after a hospital or ED visit.
• Predictable weekday schedule — structured outreach cadences without hospital shift work.
• Transitions of care career pathway — experience translates into care management, readmission prevention, and value-based care roles.
• No physical demands — no bedside care, no 12-hour shifts, no overnight coverage.
• Growing employer demand — health plans, ACOs, hospitals, and care management companies are all hiring remote transitions coordinators.

It may be particularly suitable for RNs, LPNs, and care coordination professionals who enjoy supporting members through critical transitions in a technology-enabled environment.