Post-Acute Care Transitions Navigator

Evolving Solution Services; Atlanta (GA); On-site; USD 60,000 - 80,000; Full time

Job summary

Evolving Solution Services is seeking a Post Acute Transition Coordinator to bridge hospitals, patients, and post-acute providers, ensuring smooth transitions and high-quality care across settings. The role emphasizes collaboration with clinicians and families, with an on-site travel component and focus on reducing readmissions.

The position requires a Bachelor’s degree in a health-related field and 2+ years in care coordination, discharge planning, or case management, plus proficiency with EHR

Qualifications

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field.
• 2+ years of experience in care coordination, case management, or discharge planning within a healthcare environment.
• Strong understanding of post-acute care services and patient discharge processes.
• Excellent communication, collaboration, and organizational skills.
• Proficiency with EHR systems and care management software.

Responsibilities

• Coordinate seamless care transitions from hospital discharge to skilled nursing, rehab, or home-based services.
• Develop individualized care plans by collaborating with physicians, nurses, social workers, and families.
• Communicate across settings to ensure continuity, timely documentation, and exceptional patient experiences.
• Monitor progress post-discharge and address barriers to care or readmission risks.
• Promote best practices and compliance with all care coordination and regulatory standards.
• Serve as a trusted advocate for patients and families navigating complex healthcare systems.

Skills

EHR systems

Care management software

MS Office

MS Project

Smartsheet

Asana

Communication

Education

Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field

Job description

Evolving Solution Services is seeking a Post Acute Transition Coordinator to bridge hospitals, patients, and post-acute providers, ensuring smooth transitions and high-quality care across settings. The role emphasizes collaboration with clinicians and families, with an on-site travel component and focus on reducing readmissions.

The position requires a Bachelor’s degree in a health-related field and 2+ years in care coordination, discharge planning, or case management, plus proficiency with EHR