High Risk Transitional Care Coordinator (RN) - FT Days - PAR

Job Number: 1042453

Piedmont Athens Regional Hospital - Athens, Georgia
Shift/Schedule: Full-time


The High Risk Transitional Care Coordinator (HRTCC) is responsible for the effective delivery of care and interdisciplinary collaboration of medically complex and high-risk patient populations. Ensures effective patient advocacy as well as appropriate education and support for the patient, family, and caregivers in all care settings. Oversees transitions of patient care and provides effective coordination across the continuum of care within the Piedmont system as well as with outpatient and post-acute care providers to improve patient outcomes, decrease healthcare costs, and optimize the patient experience. The HRTCC behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the health care team.



1. Collaborates with outpatient providers, case management, and post-acute care providers to ensure optimal delivery of transitional needs. 
2. Participates in activities with Piedmont Healthcare, Piedmont affiliates, and other partner organizations to improve coordination with providers to ensure a provider-to-provider handoff process is in place. 
3. Collaborates with physician and inpatient clinical staff to identify appropriate patients for care transition services, utilizing established criteria to facilitate successful care transition. 
4. Prioritizes referrals and activities according to intensity, need, and required follow-up. 
5. Performs referral mining activities and markets program to stakeholders. 
6. Serves as a guide to the patient, coaching the patient in addressing critical issues and self-management tasks rather than directly taking over and providing care. 
7. Provides information and guidance to the patient and/or family for an effective care transition, improved self-management skills, and enhanced patient-practitioner communication. 
8. Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication-self management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags. 
9. Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.


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Required qualifications for this position include:


Graduate from a school of nursing .Two years of clinical experience managing medically complex and high-risk patient populations. Registered Nurse licensed in the state of Georgia (BSN degree preferred).


Preferred qualifications for this position include: Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles.

Diversity & Inclusion

At Piedmont Healthcare we embrace diverse ideas, perspectives, and skills to create a collaborative workplace where the best talent wants to succeed. We celebrate differences and recognize that they allow us to care for our community.

Excellence at Work

Piedmont is a certified Great Place to Work™-- a national designation based on employee feedback about trust, workplace culture and experience. In 2019, Forbes named Piedmont one of Georgia’s 10 best employers and the highest-ranked healthcare provider.

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