Care Transition Associate

Compassus•Santa Rosa, CA

1d•$19 - $28•Onsite

About The Position

The Care Transition Associate coordinates safe, efficient, and patient-centered transitions of care for hospitalized patients. The role evaluates patients for appropriate post-acute home-based services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers. It focuses on improving outcomes, reducing length of stay and readmissions, and helping patients receive appropriate care in the right setting. This is an in-person role involving bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. The associate assesses clinical, functional, psychosocial, and environmental factors; coordinates individualized transition plans and post-acute services; educates patients, families, and hospital staff; and serves as a liaison between hospital teams and post-acute providers. Where applicable, the role also coordinates hospice and General Inpatient care transitions. The associate documents activities in electronic medical records and referral systems, uses clinical decision-support and predictive analytics tools, tracks referral outcomes, and supports performance goals and quality improvement initiatives. Compassus describes a culture centered on compassion, respect, appreciation, diversity, equity, inclusion, career growth, and professional development. The listed base compensation range is $18.62–$27.92; additional compensation may be available, including shift differentials, standby/on-call pay, overtime, premiums, extra-shift incentives, or bonuses.

Requirements

Associate's degree required.
No prior experience required.
Comply with all occupational health requirements of joint-venture hospital partners.
Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals, and to present information and respond to questions from leaders, teammates, patients, families, and external parties.
Strong written and verbal communication skills.
Ability to understand, read, write, and speak English.
Ability to manage multiple projects simultaneously and meet deadlines.
Regular standing and walking, manual dexterity, and ability to lift and move objects up to 50 pounds.
Visual acuity for close and distance vision, color and peripheral vision, depth perception, and adjustment of focus.

Nice To Haves

Bachelor's degree.
Two to three years of experience in a healthcare setting, such as a hospital or long-term care.
Experience in liaison work, care coordination, partnerships, or discharge planning.
Ability to articulate and embrace hospice philosophy.
Ability to design accessible and inclusive learning experiences for a diverse workforce.

Responsibilities

Evaluate patients for home-based and post-acute care services using clinical, functional, psychosocial, and environmental factors.
Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools.
Collaborate with physicians and care teams on appropriate level-of-care decisions and identify patients suitable for value-based post-acute services.
Coordinate and facilitate timely, safe, and appropriate hospital discharge planning.
Develop and implement individualized transition-of-care plans aligned with patient needs and clinical goals.
Partner with physicians, advanced practice providers, case management, and nursing teams.
Arrange post-acute services, including home health, hospice, durable medical equipment, medications, and follow-up care.
Ensure accurate and timely patient handoffs to post-acute providers.
Educate patients and families about post-acute care options, expectations, and available services, supporting informed choice and shared decision-making.
Educate hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care principles, and site-of-care selection.
Serve as a liaison between hospital teams and post-acute providers and maintain relationships with physicians, case management, nursing teams, and discharge planners.
Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions; strengthen referral network partnerships.
When applicable, identify patients appropriate for hospice or General Inpatient care and coordinate hospice evaluations, eligibility determinations, and admissions.
Support end-of-life transitions with clinical urgency and patient-centered communication, ensuring alignment with hospice eligibility requirements and physician certification processes.
Accurately and promptly document care coordination activities in the electronic medical record.
Manage referrals through designated hospital and post-acute systems, use clinical decision-support and predictive analytics platforms, and track referrals, outcomes, and transitions across systems.
Support value-based engagement performance goals and care coordination strategy, including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, referral quality, and documentation accuracy.
Participate in quality improvement and workflow optimization initiatives and support efforts to improve post-acute network performance and patient outcomes.