Care Transition Associate

Company: Providence at Home with Compassus

Position Summary

The Care Transition Associate provides non-clinical administrative and care coordination support within acute care hospital hubs for patients requiring home health and hospice services. The role assists patients, families, hospital care teams, and post-acute care providers with referrals, discharge arrangements, and the coordination of services needed to support a timely start of care. The Care Transition Associate also supports Care Partners and Clinical Care Partners, maintains positive relationships with referral sources, and participates in educational outreach and other care coordination activities.

Major Challenges

• Managing competing priorities in a demanding and changing healthcare environment while maintaining accuracy and customer service.
• Building effective relationships with patients, families, hospital teams, and post-acute care providers.
• Understanding and supporting the purpose and function of Value-Based Enterprise agreements for home health and hospice care coordination.

Position Specific Responsibilities

The job duties listed are essential functions of the position. However, other duties may be assigned and may also be considered essential functions of the position. The team member must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending on the nature of the position. Team members are expected to honor the Mission, Values, Vision and Promise and adhere to the Code of Conduct, policies and standards of their organization.

• Serves 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.
• Coordinates referral and admission activities, including collecting and verifying patient demographic, insurance, medical, and other pertinent information; obtaining required orders and documentation; and assisting with scheduling starts of care.
• Obtains and organizes information to support clinical assessment of patient appropriateness for home health and hospice services.
• Collaborates with clinical team members to coordinate services and equipment consistent with applicable orders, admission criteria, and patient needs.
• Communicates with physicians, provider offices, hospital discharge planners, and other referral sources to verify orders, identify following providers, obtain necessary information, and address barriers to timely discharge and start of care.
• Provides administrative support to Care Partners and Clinical Care Partners, including accurate electronic medical record documentation, chart organization, referral and reimbursement coordination, and distribution of information to internal and external agencies.
• Provides patients and families with information and educational materials regarding home health and hospice services, verifies pertinent information, and coordinates equipment delivery with appropriate vendors to support timely discharge.
• Maintains knowledge of community resources, payer criteria, managed care contracts, network provider arrangements, and durable medical equipment resources to support effective care coordination.
• Builds and maintains positive relationships with hospital care teams, physician groups, referral sources, and post-acute care providers.
• Supports educational outreach, service updates, meetings, reporting, and training activities as assigned.
• Monitors care arrangements, follows up on outstanding needs, and resolves customer service concerns within the scope of the role.
• Escalates clinical concerns, changes in patient condition, or other issues to appropriate team members or leadership.
• Adheres to applicable policies, procedures, and regulatory requirements, including HIPAA, confidentiality, infection control, safety, and disaster preparedness.
• Participates in required training and performs other duties as assigned.

Education and/or Experience Required

Associate’s degree or equivalent education and experience. A high school diploma or equivalent plus three (3) years of work experience is equivalent to an Associate’s degree. Required: One (1) Year of experience working with patients and families and providing customer service and administrative support, preferably in a healthcare setting.

Preferred

Two (2) or more years of relevant healthcare experience; healthcare-related coursework or training, including medical terminology; proficiency in Microsoft Word and Excel; and experience with Epic or other electronic medical record systems.

Skills

• Communication and Customer Service: Strong written and verbal communication skills, with 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.
• Organization and Problem Solving: Strong organizational, customer service, and problem-solving skills, including the ability to manage competing priorities, adapt to change, remain calm under pressure, and maintain attention to detail.
• Healthcare and Care Coordination Knowledge: Understanding of home health and hospice care coordination, Value-Based Enterprise agreements, and applicable referral processes, payer criteria, and community resources. Medical terminology knowledge preferred.
• Technical and Mathematical Skills: 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.

Certifications, Licenses, and Registrations

No requirements.

Physical Demands and Work Environment

The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 25 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

Equal Opportunity Employer

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation.

Compensation

$22.34 - $33.50

Build a Rewarding Career with Compassus

At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others. Your Career Journey Matters. We’re dedicated to helping you grow and succeed. Whether you’re pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.

The Compassus Advantage

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well‑being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

Ready to Join?

At Compassus, your career is more than a job—it’s an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.

Compassus provides a continuum of integrated home-based services including home health, home infusion, palliative and hospice care. Thousands of teammates and hundreds of access points nationwide provide high-quality care and manage patients’ advanced illnesses in partnership with health systems and long-term care partners. The Compassus Care for who I am culture reflects its unique care delivery model, which focuses on each person as an individual as well as a patient, to improve their quality of life in a meaningful way.

Learn more at compassus.com or follow @Compassus on Facebook, LinkedIn, Instagram or Twitter.