RN Care Transitions Specialist

Compassus; Olympia (WA); On-site; USD 81,664,000 - 122,496,000; Full time

Benefits offered by this job

Competitive pay

Job summary

Compassus is seeking a Clinical Care Partner to coordinate safe, efficient transitions of care for hospitalized patients. This in-person role focuses on evaluating post-acute home-based care needs, coordinating discharge planning, and ensuring timely handoffs to post-acute providers.

Collaboration with physicians, case management, and families is essential to align with patient goals. The role emphasizes value-based care, education for patients and staff, and engagement across interdisciplinary

Qualifications

• RN license active and unencumbered
• Experience with EMR systems (Epic) and referral platforms
• Excellent written and verbal communication
• Ability to manage multiple projects and meet deadlines

Responsibilities

• Evaluate patients for appropriateness for home-based and post-acute care services
• Coordinate timely, safe hospital discharges and transition plans
• Educate patients and families on post-acute options and care expectations
• Serve as liaison between hospital teams and post-acute providers to support referrals and placements
• Identify patients for hospice or GIP levels of care and manage eligibility processes
• Document all care coordination activities in the EMR and track referrals

Skills

Communication

Clinical coordination

Discharge planning

Education

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

Bachelor’s degree preferred

Job description

Compassus is seeking a Clinical Care Partner to coordinate safe, efficient transitions of care for hospitalized patients. This in-person role focuses on evaluating post-acute home-based care needs, coordinating discharge planning, and ensuring timely handoffs to post-acute providers.

Collaboration with physicians, case management, and families is essential to align with patient goals. The role emphasizes value-based care, education for patients and staff, and engagement across interdisciplinary