Care Transitions Navigator – Post-Acute & Discharge

Providence at Home with Compassus; Napa (CA); On-site; USD 43,000 - 53,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Wellness programs

Flexible time off

Job summary

Qualifications

• Required: Associate’s degree in Nursing, Health Sciences, or related field.
• Preferred: Bachelor’s degree in nursing, Health Sciences, or related field.
• Preferred: 2–3 years of experience in care coordination, discharge planning, or post-acute care.
• Experience with EMR systems (Epic) is expected.

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 discharge planning and care transitions.
• Develop and implement individualized transition-of-care plans aligned with patient needs.
• Educate patients and families on post-acute care options and care expectations.
• Manage referrals and ensure accurate documentation in the EMR.

Skills

Communication skills

Care coordination

Discharge planning

Documentation

Education

Associate’s degree in Nursing

Bachelor’s degree preferred

Tools

Epic

Job description