Care Transitions Navigator

Providence at Home with Compassus; Mission Viejo (CA); On-site; USD 37,000 - 56,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Wellness programs

Job summary

Providence at Home with Compassus is seeking a Care Partner to coordinate safe, patient-centered transitions of care for hospitalized patients. You will assess suitability for home-based and post-acute services, support discharge planning, and collaborate with physicians, case management, families, and post-acute providers in person.

Responsibilities include coordinating timely discharges, developing individualized transition plans, educating patients and families, and maintaining post-acute

Qualifications

• Education: Associate's degree required; Bachelor's degree preferred.
• Experience: Preferred 2–3 years in a healthcare setting (hospital and/or long-term care). Liaison, care coordination, partner, and/or discharge planning experience preferred.

Responsibilities

• Evaluate patients for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factors.
• Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools.
• Coordinate and facilitate timely, safe hospital discharge planning and transition-of-care plans.
• Educate patients and families on post-acute care options and care expectations.
• Serve as liaison between hospital teams and post-acute providers to support timely referrals and placements.
• Identify patients appropriate for hospice and/or GIP level of care; coordinate related evaluations and admissions.
• Document all care coordination activities in the electronic medical record and manage referrals through systems.
• Support VBE performance goals and care coordination strategy and participate in quality improvement initiatives.

Skills

Communication skills

English proficiency

Education

Associate's degree

Bachelor's degree

Job description

Providence at Home with Compassus is seeking a Care Partner to coordinate safe, patient-centered transitions of care for hospitalized patients. You will assess suitability for home-based and post-acute services, support discharge planning, and collaborate with physicians, case management, families, and post-acute providers in person.

Responsibilities include coordinating timely discharges, developing individualized transition plans, educating patients and families, and maintaining post-acute