Care Transitions Specialist: Discharge to Home

Compassus; Mission Viejo (CA); On-site; USD 41,000 - 62,000; Full time

Benefits offered by this job

Competitive pay

Flexible time off

Tuition reimbursement

Wellness programs

Job summary

Providence at Home with Compassus seeks a Clinical Care Partner I to coordinate safe, efficient transitions of care for hospitalized patients. The role evaluates patients for post-acute home-based services and supports discharge planning in collaboration with physicians, case management, families, and post-acute providers.

This in-person role requires bedside engagement, interdisciplinary collaboration, and active participation in discharge workflows to improve outcomes, reduce length of stay,

Qualifications

• Education Required: Associate’s degree in Nursing, Health Sciences, or related field.
• Preferred: Bachelor’s degree in nursing, Health Sciences, or related field.
• Experience Required: None
• Preferred: 2–3 years of experience in care coordination, discharge planning, or healthcare services.
• Experience with hospital, home health, hospice, or post-acute care.
• Experience working with EMR systems (Epic) and referral platforms.

Responsibilities

• Evaluate patients for home-based and post-acute care services based on clinical factors.
• Coordinate and facilitate hospital discharge planning and transitions of care.
• Educate patients and families on post-acute options and care expectations.
• Maintain relationships with physicians, case management, nursing teams, and discharge planners.
• Identify hospice or GIP needs and coordinate related evaluations and admissions.
• Document activities in the EMR and support KPI tracking and care coordination.

Skills

Communication

English proficiency

Discharge planning

Care coordination

Multitasking

Education

Associate’s degree in Nursing, Health Sciences, or related field

Bachelor’s degree in Nursing, Health Sciences, or related field

Tools

Epic EMR

Referral platforms

Job description

Providence at Home with Compassus seeks a Clinical Care Partner I to coordinate safe, efficient transitions of care for hospitalized patients. The role evaluates patients for post-acute home-based services and supports discharge planning in collaboration with physicians, case management, families, and post-acute providers.

This in-person role requires bedside engagement, interdisciplinary collaboration, and active participation in discharge workflows to improve outcomes, reduce length of stay,