Job Description


Transition of Care Specialist

Revival Home Health Care is actively looking to hire a Transition of Care Specialist to work for our Certified Home Health Agency. 

The Transition of Care Specialist facilitates a safe and effective discharge of members from the hospital setting to the community. In collaboration with clinical teams, the Specialist provides information, guidance, and care coordination for care transition from hospital to community.


  • Conducts telephonic assessment of members status and discharge plans with hospital(s).
  • Evaluates discharge plan and appropriateness of discharge status, in coordination with CM department.
  • Serves as a guide to the hospital discharge planner to promote better understanding of healthcare issues and ongoing care needs the member may have.
  • Evaluates/reviews discharge summary/homecare needs and support systems to formulate a plan that will lead to, appropriate referral(s) to community or other programs (i.e. Hospice, Palliative care, home care services) as appropriate.
  • Engages with Care management team as needed to collaboratively work on members discharge needs (if applicable).
  • Completes required documentation in a timely manner.
  • Other duties as assigned.


  • BSW degree preferred.
  • Some knowledge of Case Management in a health care setting, experience in a MLTC, Managed Care, Home Care or Community Health Setting preferred
  • Excellent interpersonal, verbal and written skills.
  • Able to communicate effectively on the telephone.


  • Office Based Position
  • Full Time
  • Attractive Benefits Package
  • Biweekly Pay Frequency


  • Margate, Florida


About Us:

Centers Home Care is one of the largest home health care organizations in New York, providing every type of healthcare from Health aide to Physical Therapists, Registered Nurses, and more. Our network includes Alpine Home Health Care, Revival Home Health Care, InterGen Health, and Amazing Home Care. Whether you are a hospital planner arranging patient discharges, a rehabilitation patient in need of continuing care when you return home, or you’re taking care of someone at home and need a little extra help, we’re here for you. We have the staff and most importantly, we have the expertise. We can solve your care needs, assist you with short or long-term equipment rental, and resolve insurance questions all with one call.


Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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