Care Transition Specialist
NH
Part Time to Full Time
Entry Level
Job Summary:
The Care Transition Specialist plays a critical role in ensuring seamless initiation of services for newly admitted clients by providing immediate coverage during the transition period prior to assignment of a permanent caregiver. This position supports timely admissions, continuity of care, and high-quality client experience by stabilizing new cases while permanent caregivers complete onboarding and orientation requirements.
As the first caregiver assigned to a new client, the Care Transition Specialist establishes rapport with clients and families, implements the initial care plan, observes and reports client needs, and communicates relevant updates to the clinical and operations teams. The specialist serves as a key liaison during the early stage of service delivery, helping identify adjustments needed to promote long-term success and caregiver matching.
The Care Transition Specialist also facilitates a structured and professional handoff to the permanent caregiver, ensuring continuity, clear communication, and a smooth transition of care. This role operates under the direction and supervision of the Clinical Director and the VP of Operations and directly supports agency growth, client retention, and service reliability by preventing delays in care initiation and reducing admission related service gaps.
Educational and Professional:
Knowledge and Abilities:
Responsibilities:
Tools/Equipment:
Hoyer Lift Glucose monitors or meters - Glucometers
Gait Belt Therapeutic ice packs or pillows – Ice caps; Ice collars
Sharps disposal Walker
Wheelchair Cane
Tub seat Transfer/slide board
Physical Demands:
Aptitudes:
Can understand verbal and written instructions. Read and write documentation in patient record. Work with the hands and fingers to manipulate large and small objects.
Guardian Home Care of NH, LLC’s Dedication:
We are committed to embodying the essence of exceptional care and hospitality, ensuring that both our staff and clients experience the utmost respect and attention to detail in every interaction. This entails:
Guardian Home Care of NH, LLC is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
The Care Transition Specialist plays a critical role in ensuring seamless initiation of services for newly admitted clients by providing immediate coverage during the transition period prior to assignment of a permanent caregiver. This position supports timely admissions, continuity of care, and high-quality client experience by stabilizing new cases while permanent caregivers complete onboarding and orientation requirements.
As the first caregiver assigned to a new client, the Care Transition Specialist establishes rapport with clients and families, implements the initial care plan, observes and reports client needs, and communicates relevant updates to the clinical and operations teams. The specialist serves as a key liaison during the early stage of service delivery, helping identify adjustments needed to promote long-term success and caregiver matching.
The Care Transition Specialist also facilitates a structured and professional handoff to the permanent caregiver, ensuring continuity, clear communication, and a smooth transition of care. This role operates under the direction and supervision of the Clinical Director and the VP of Operations and directly supports agency growth, client retention, and service reliability by preventing delays in care initiation and reducing admission related service gaps.
Educational and Professional:
- High School Diploma or GED
- Successful completion of any required training programs that meet State and agency regulations.
- Show evidence of fulfilling the State health requirements.
- Valid drivers’ license
- Must be 18 years or older
- Successfully complete 12 in-services by December 1 of current year
- 6 Hours initial of Dementia Training and 4 hours yearly continued
- Prior experience in home care is required
- LNA certification is preferred but not required
Knowledge and Abilities:
- Knowledgeable in-home care rules and regulations
- Be aware of and adhere to all HIPAA rules and regulations and must be an active participant in safety measures for ensuring confidentiality of information as it relates to clients and this agency
- Good oral, written and reading communication skills. Have the ability to understand verbal and written instructions. Read and write documentation.
- Resourcefulness, flexibility, and integrity. Ability to work independently. Ability to function in a team oriented environment
- Ability to make meaningful observations and write brief and accurate reports when necessary
Responsibilities:
- Review Plan of Care prior to first shift
- Establish rapport with client and family
- Maintain flexibility during onboarding period
- Participate in transition planning
- Provide structured handoff to permanent caregiver
- Assist client with personal hygiene (bathing, shampooing, shaving, oral hygiene)
- Assist with dressing, ambulation, toileting, and safe transfer techniques per Plan of Care
- Prompt client with self-administered medications per care plan
- Assist with physician-ordered treatments/therapies as approved and supervised by RN
- Carry out assignments per the client’s care plan
- Notify scheduling and Clinical Director if unable to complete assigned care
- Plan and prepare nutritious meals or modified diets as prescribed
- Assist with activities of daily living (ADLs) as directed
- Perform routine housekeeping to maintain a safe and comfortable environment
- Accompany client to authorized appointments (when approved by office)
- Report changes in client condition or home situation immediately
- Maintain accurate documentation through Mobile App
- Follow EVV compliance procedures
- Respect client cultural and religious practices
- Maintain neat, clean, orderly appearance (Dress Code Policy)
- Conduct oneself in a manner that promotes client safety
- Perform additional duties as directed by Director of Client Services, Administrator, or designee
- Provide client routine overview to permanent caregiver
- Communicate client preferences and observations
- Participate in overlap shift when possible
Tools/Equipment:
Hoyer Lift Glucose monitors or meters - Glucometers
Gait Belt Therapeutic ice packs or pillows – Ice caps; Ice collars
Sharps disposal Walker
Wheelchair Cane
Tub seat Transfer/slide board
Physical Demands:
- Lifting, carrying, pushing, or pulling up to 50 pounds
- Patient transfers with no assistance for direct patient care
- Standing, walking, stair climbing, stooping, kneeling, and crouching while administering patient care in the home
- Reaching and handling
- Adequate eyesight for reading, writing, driving, and performing tasks
Aptitudes:
Can understand verbal and written instructions. Read and write documentation in patient record. Work with the hands and fingers to manipulate large and small objects.
Guardian Home Care of NH, LLC’s Dedication:
We are committed to embodying the essence of exceptional care and hospitality, ensuring that both our staff and clients experience the utmost respect and attention to detail in every interaction. This entails:
- Cultivating enduring relationships built on mutual respect
- Establishing trust with our clients through exemplary conduct
- Creating an environment where clients feel embraced and valued
- Delivering unparalleled service quality
- Interacting with every client in a manner that honors their dignity and worth
- Giving priority to communication initiated by any Guardian Home Care of NH, LLC team member seeking assistance for a client.
Guardian Home Care of NH, LLC is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
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