Care Transition Associate

Compassus•Nashville, TN

About The Position

The Care Transition Associate provides non-clinical administrative and care coordination support within acute care hospital hubs for patients who need home health or hospice services. The position supports patients, families, hospital care teams, Care Partners, Clinical Care Partners, and post-acute care providers with referrals, discharge arrangements, and coordination of services needed for a timely start of care. The role coordinates referral and admission activities, gathers and verifies patient and insurance information, obtains required orders and documentation, supports clinical assessment of service appropriateness, and helps arrange services and equipment. It also provides administrative support, maintains electronic medical record documentation, communicates with referral sources, shares service information with patients and families, and follows up on care arrangements and outstanding needs. The associate maintains knowledge of community resources, payer criteria, contracts, and provider arrangements, and supports relationship-building, educational outreach, reporting, meetings, and training. The position requires effective communication and customer service, organization, problem-solving, adaptability, attention to detail, and proficiency with electronic records and standard office applications. The role must comply with applicable policies and regulatory requirements, including HIPAA, confidentiality, infection control, safety, and disaster preparedness. Regular standing, walking, and manual dexterity are required, as well as the ability to lift and move objects up to 25 pounds.

Requirements

Associate’s degree or equivalent education and experience. A high school diploma or equivalent plus three years of work experience is considered equivalent to an Associate’s degree.
One year of experience working with patients and families and providing customer service and administrative support, preferably in a healthcare setting.
Strong written and verbal communication skills and the ability to communicate professionally and sensitively with patients, families, healthcare professionals, and external stakeholders.
Ability to develop collaborative working relationships and provide effective customer service.
Strong organizational and problem-solving skills, including the ability to manage competing priorities, adapt to change, remain calm under pressure, and maintain attention to detail.
Understanding of home health and hospice care coordination, Value-Based Enterprise agreements, referral processes, payer criteria, and community resources.
Proficiency with electronic medical records, standard computer applications, and office equipment.
Ability to maintain accurate documentation and perform basic arithmetic, including calculations involving rates, ratios, and percentages.
Ability to perform regular standing, walking, and manual dexterity tasks and lift and move objects up to 25 pounds.
No certifications, licenses, or registrations are required.

Nice To Haves

Two or more years of relevant healthcare experience.
Healthcare-related coursework or training, including medical terminology.
Proficiency in Microsoft Word and Excel.
Experience with Epic or other electronic medical record systems.

Responsibilities

Serve as a non-clinical liaison between inpatient and outpatient settings, supporting Care Partners, Clinical Care Partners, and hospital care teams with home health and hospice referrals and discharge arrangements.
Coordinate referrals and admissions by collecting and verifying patient demographic, insurance, medical, and other pertinent information; obtaining required orders and documentation; and assisting with start-of-care scheduling.
Gather and organize information to support clinical assessment of patient appropriateness for home health and hospice services.
Collaborate with clinical team members to coordinate services and equipment consistent with applicable orders, admission criteria, and patient needs.
Communicate with physicians, provider offices, hospital discharge planners, and other referral sources to verify orders, identify following providers, obtain information, and address barriers to timely discharge and start of care.
Provide administrative support to Care Partners and Clinical Care Partners, including electronic medical record documentation, chart organization, referral and reimbursement coordination, and distribution of information to internal and external agencies.
Provide patients and families with information and educational materials regarding home health and hospice services, verify pertinent information, and coordinate equipment delivery with vendors.
Maintain knowledge of community resources, payer criteria, managed care contracts, network provider arrangements, and durable medical equipment resources.
Build and maintain positive relationships with hospital care teams, physician groups, referral sources, and post-acute care providers.
Support educational outreach, service updates, meetings, reporting, and training activities as assigned.
Monitor care arrangements, follow up on outstanding needs, and resolve customer service concerns within the scope of the role.
Escalate clinical concerns, changes in patient condition, and other issues to appropriate team members or leadership.
Adhere to policies, procedures, and regulatory requirements, including HIPAA, confidentiality, infection control, safety, and disaster preparedness; participate in required training and perform other assigned duties.