Transitions of Care Associate

TL;DR

Transitions of Care Associate: Supporting members after hospital discharge by coordinating care and resources with an accent on patient advocacy, vendor coordination, and preventing hospital readmissions. Focus on calling patients post-discharge, scheduling follow-up visits, and escalating needs to the clinical team to ensure safe recovery at home.

Location: Remote (USA)

Salary: $23.00–$27.00 / hour

Company

hirify.global helps older Americans navigate healthcare and deliver integrated care.

What you will do

• Call patients (inbound/outbound) after discharge to confirm they received needed assistance and are recovering safely.
• Coordinate services with affiliated vendors, including transportation, DME, meals, and home health care.
• Schedule post-discharge TOC APP, PCP, and specialist visits.
• Collaborate with patients, providers, and caregivers to drive positive outcomes.
• Coordinate with the TOC team on patient needs, including interdisciplinary huddles.
• Access discharge records, participate in pilot programs, and escalate issues to the clinical team using established processes.

Requirements

• Medical Assistant Certification (active and clear).
• 2–3 years of experience in healthcare, managed care, home health, and/or community health settings.
• Fully bilingual in English and Spanish.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• 401K program and parental leave program.
• Bonus eligibility for roles excluding Director and above.