Care Transitions Specialist

Southern California Hospitals; Culver City (CA); On-site; USD 50,000 - 67,000; Full time

Job summary

Southern California Hospitals is seeking a Discharge Planner to coordinate social services and discharge planning for patients. The role involves psychosocial evaluation, advocacy, referrals, and documentation to support safe, timely transitions from hospital to home or care facilities.

The position requires a social work degree, CMS/Medicare knowledge, BLS, and strong communication. Collaboration with physicians, staff, and families is essential to ensure optimal patient outcomes.

Qualifications

• BSW or related degree in human services is required.
• Knowledge of CMS/Medicare/Medi-Cal is required.
• Familiarity with Joint Commission, CMS, and CDPH requirements.
• Excellent written and verbal English communication.
• Ability to collaborate across the organization.
• Ability to facilitate interdisciplinary rounds.
• AHA Basic Life Support (BLS) required.
• De-escalation certification on hire; SAMA certification on recertification.
• Hospital Fire & Life Safety Card (LA City Employees only).

Responsibilities

• Interview patients and significant others to obtain information for discharge planning.
• Communicate social and family information to attending physicians and care teams.
• Determine social assessments and arrange post-hospital services and referrals.
• Ensure HIPAA compliance and clear documentation in the medical record.
• Participate in interdisciplinary rounds and coordinate with community resources.
• Assist in department studies and projects as required.

Skills

Communication

Interdisciplinary teamwork

De-escalation

AHA BLS

CMS/Medicare knowledge

Regulatory knowledge

English fluency

Relationship management

Fire & safety

SAMA certification

Education

BSW or related degree

Job description

Southern California Hospitals is seeking a Discharge Planner to coordinate social services and discharge planning for patients. The role involves psychosocial evaluation, advocacy, referrals, and documentation to support safe, timely transitions from hospital to home or care facilities.

The position requires a social work degree, CMS/Medicare knowledge, BLS, and strong communication. Collaboration with physicians, staff, and families is essential to ensure optimal patient outcomes.