Job Information

Transition Coach in Shawnee, Kansas


Transition Coach

All the benefits and perks you need for you and your family:

  • Benefits from Day One for eligible employees

  • Paid Days Off from Day One

  • Student Loan Repayment Program

  • Career Development

  • Whole Person Wellbeing Resources

  • Mental Health Resources and Support

  • Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Part Time, Days

Shift : 24 Hours per week – MWF 8 hour shifts

Location: 9100 W 74 th Street, Merriam, KS 66204

The community you’ll be caring for:

At AdventHealth Shawnee Mission, formerly Shawnee Mission Medical Center, you're more than just a number on a chart. You're a whole person, who functions best when physically, emotionally, and spiritually fit. Find whole-person care, dedicated teams and staff, and a wide variety of medical services, all at our hospital in Shawnee Mission, Kansas.

The role you’ll contribute:

The Transition Coach will implement the Shawnee Mission Health Readmission Prevention model targeted to reduce the number of patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. The Transition Coach will initially meet patients in the hospital and will follow selected patients who transition from the hospital to a lower level of care. Patients will be identified by various methods including the use of Cerner Quality Consoles, Care Coordination meetings and the BOOST tool. Strategies for patient management include but are not limited to Teach Back method of discharge instruction, assistance in setting up PCP appointment within 72 hours, home visits to assist with medication reconciliation and other self -management techniques, ongoing telephone follow up, assistance with psychosocial issues and gaps in service and support of caregivers as appropriate. Transition management will be provided to patients who discharge to a destination other than home and the strategies will be appropriate to that level of care. The Transition Coach will work as part of an interdisciplinary Transitions Team including acute care case managers, social workers, home care liaisons, physicians, pharmacists, nursing leadership and staff nursing. This position will also work as part of various other teams, including the Continuing Care Team on each unit. The Transition Coach will also participate in routine readmission meetings with community partners as well as comply with data collection expectations

The value you’ll bring to the team:

  • Attend in service programs of continuing education and review current literature as a means to evaluate and enhance current treatment practices.

  • Adjust and enhance clinical expertise to meet changing healthcare needs.

  • Incorporate and maintain a professional practice pattern that includes assessment of psychosocial functioning, adaptation to illness, post hospital planning, and psychosocial assessment/evaluation and facilitates referrals to community agencies, financial planning and provision of information and resource knowledge.

  • Apply appropriate criteria to identify patients who are at high risk for readmission or for high emergency room utilization.

  • Conduct patient and family education, utilizing Teach Back method.

  • Identify and advocate of client needs lacking in community systems

  • Function as a treatment team member, interpreting social, psychological, emotional and family system problems and strengths to other members of the treatment team.

  • Incorporates patient, physician, customer needs and concerns into decision-making and organizational action.


The expertise and experiences you’ll need to succeed:

  • Bachelors Degree in Nursing OR Master’s Degree in Social Work required

  • 1-2 years of position related experience required

  • 2-5 years of position related experience preferred

  • Kansas RN License OR Kansas Licensed Master Social Worker (LMSW) or Kansas Licensed Specialist Clinical Social Worker (LSCSW) required

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Case Management

Organization: AdventHealth Shawnee Mission

Schedule: 1 - Day

Shift: AdventHealth Shawnee Mission

Req ID: 22036735

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.