Care Transitions Specialist: Hospital to Home

Compassus; Spokane (WA); Sur place; USD 37 000 - 56 000; Plein temps

Avantages offerts par ce poste

Competitive pay

Tuition reimbursement

Wellness programs

Flexible time off

Career development

Culture of belonging

Résumé du poste

Providence at Home with Compassus seeks a Clinical Care Partner to coordinate safe transitions of care for hospitalized patients, ensuring appropriate post-acute home-based services and timely discharge planning. This in-person role emphasizes bedside engagement and interdisciplinary collaboration to improve outcomes and reduce length of stay.

Responsibilities include evaluating referrals, coordinating post-acute services, educating patients and families, and maintaining accurate documentation.

Qualifications

• Associate degree in Nursing or related health field; Bachelor’s preferred.
• Experience with care coordination, discharge planning, or post-acute care is desirable.
• Experience with EMR systems such as Epic and referral platforms.

Responsabilités

• Evaluate patients for home-based and post-acute care services based on clinical factors.
• Coordinate timely, safe discharge planning and transitions of care.
• Educate patients and families on post-acute options and care expectations.
• Manage relationships with physicians, case management, nursing teams, and post-acute providers.
• Identify hospice or GIP candidates and coordinate associated processes.
• Document activities in the EMR and monitor referrals and outcomes.

Formation

Associate degree in Nursing

Bachelor's degree in Nursing/Health Sciences

Outils

Epic EMR

Referral platforms

Description du poste

Providence at Home with Compassus seeks a Clinical Care Partner to coordinate safe transitions of care for hospitalized patients, ensuring appropriate post-acute home-based services and timely discharge planning. This in-person role emphasizes bedside engagement and interdisciplinary collaboration to improve outcomes and reduce length of stay.

Responsibilities include evaluating referrals, coordinating post-acute services, educating patients and families, and maintaining accurate documentation.