Care Guide Discharge Planning

Job Description

Summary ‎ The Care Guide II supports Acute/Post Acute care coordination and discharge planning activities by partnering with hospital and post-acute case management teams, internal nurses, and post-acute providers. This role focuses on executing discharge plans, facilitating communication, and ensuring timely coordination of services to support safe transitions of care and reduce readmissions. The Care Guide operates within a structured model alongside utilization management and post-acute services with defined outreach cadences, escalation pathways, and collaboration across interdisciplinary teams. ‎ How will you make an impact & Requirements ‎ Support inpatient case tracking and coordination for high‑risk and readmission‑prone populations. Partner with hospital/post-acute Case Managers and Discharge Planners to align on clinical status, discharge plans, and barriers to timely discharge Coordinate post‑acute services, including Home Health, DME, and facility placements (SNF, IRF, LTACH, subacute) in collaboration with post‑acute teams. Conduct regular outreach to hospital/post-acute teams to monitor discharge progress and identify barriers. Serve as a liaison between hospital partners, internal nursing teams, and post‑acute providers to ensure alignment and timely execution of discharge plans. Escalate complex cases, clinical concerns, or discharge barriers to care managers or leadership as appropriate. Participate in interdisciplinary communication, reporting, and discharge planning activities.

Qualifications

Required: 2+ years of experience in: Acute care, care coordination, discharge planning, or case management support Knowledge of post-acute care services (HH, DME, post-acute, etc.) Strong organizational and communication skills High School Diploma or GED Preferred: Experience in managed care or health plan environment Experience supporting high-risk or readmission populations Core Competencies Care coordination and task execution Communication and follow-through Organization and time management Team collaboration Problem identification and escalation Working Environment Potentially Hybrid role interacting with hospital teams, health plan partners, and post-acute providers Requires frequent communication, case tracking, and real-time coordination across multiple stakeholders Potential for weekend/evening coverage ‎ Compensation: $22.00 to $33.00 Beware of fraudulent job postings: While Mosaic Health job advertisements may be found on many sites, our current openings page and its associated Workday account are the only places we accept applications for open roles. If you suspect a job post is fraudulent, please let us know at recruiting@apree.health. Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. Learn More about Mosaic Health Learn More about Millennium Physician Group Learn More about CareMore Health Learn More about Castlight Health Learn More about Vera Whole Health