Care Transition Manager Jobs in Springfield, VA (NOW HIRING)

Location: Primarily onsite in the Rockville, Maryland region, Monday–Friday, 8:00 AM–5:00 PM 

Role Overview 

Avail Health is seeking a compassionate, relationship-driven Care Navigator, Enrollment Partner to serve as our primary onsite representative within a hospital setting. In this role, you’ll help patients make a smooth transition from hospital to home by identifying eligible patients, introducing Avail Health’s Care Transitions Program, facilitating enrollment, and ensuring every patient leaves the hospital with a clear plan and a scheduled follow-up appointment. 

As the first face many patients and caregivers encounter from Avail Health, you’ll play a critical role in building trust, creating a positive patient experience, and strengthening our partnership with hospital teams. This position is ideal for someone who enjoys connecting with people, thrives in a fast-paced healthcare environment, and is passionate about improving care for older adults and individuals with complex medical and behavioral health needs. 

As part of a rapidly growing organization, you’ll also have the opportunity to influence workflows, improve patient engagement strategies, and help shape the future of our Care Transitions Program. 

Before You Apply 

We’re looking for someone who enjoys working directly with patients and caregivers while serving as a trusted partner within a hospital environment. To be successful in this role, you should have at least two years of experience in healthcare patient engagement, care coordination, patient access, healthcare operations, community outreach, or a related field. You should be comfortable building relationships with patients experiencing complex medical, behavioral health, cognitive, and psychosocial needs while providing exceptional customer service in a fast-paced clinical setting. 

The ideal candidate has experience enrolling patients into healthcare programs, is highly organized, comfortable using electronic medical records and multiple technology platforms, and enjoys collaborating with interdisciplinary teams while working independently. Experience with Medicare populations, hospital care coordination, healthcare outreach, or value-based care programs is highly desirable. 

What You’ll Own 

• Building trusted relationships with patients, caregivers, and hospital care teams from the very first interaction. 

• Identifying eligible patients and successfully enrolling them into Avail Health’s Care Transitions Program before hospital discharge. 

• Creating a seamless, patient-centered transition from hospital to home through thoughtful coordination and communication. 

• Serving as Avail Health’s onsite ambassador while strengthening hospital partnerships and referral relationships. 

• Ensuring every enrolled patient has completed documentation, required consents, and a scheduled follow-up appointment before discharge. 

• Identifying workflow improvements that enhance patient engagement, operational efficiency, and program growth. 

What You’ll Do 

• Serve as Avail Health’s primary onsite representative within the assigned hospital. 

• Partner with hospital care navigation teams to identify patients who may benefit from the Care Transitions Program. 

• Meet with patients and caregivers to explain the program, answer questions, and build confidence in Avail Health’s services. 

• Facilitate enrollment, obtain required consents, and complete enrollment documentation. 

• Schedule each patient’s initial Care Transitions appointment before discharge. 

• Coordinate warm handoffs between hospital staff and Avail Health’s interdisciplinary care team. 

• Communicate enrollment status and operational updates to virtual clinical team members. 

• Escalate clinical questions or concerns to Care Transitions RN or Social Work Care Managers as appropriate. 

• Maintain accurate documentation within hospital systems, Avail Health’s EHR, and operational platforms. 

• Participate in workflow improvements that strengthen hospital partnerships and improve the patient experience. 

What Success Looks Like 

• Eligible patients are identified and enrolled before discharge. 

• Patients leave the hospital with a scheduled initial appointment and a clear understanding of next steps. 

• Hospital partners view Avail Health as a trusted, collaborative resource. 

• Enrollment documentation is accurate, timely, and complete. 

• Enrollment conversion goals are consistently achieved while maintaining an exceptional patient experience. 

• Operational insights contribute to ongoing workflow refinement and program growth. 

What You Bring 

Required Qualifications 

• High school diploma required; Associate’s or Bachelor’s degree preferred. 

• Two or more years of experience in healthcare patient engagement, care coordination, patient access, practice operations, community outreach, or related healthcare operations. 

• Experience enrolling patients into healthcare programs or value-based care initiatives. 

• Strong interpersonal skills with the ability to establish trust and build rapport quickly. 

• Demonstrated commitment to exceptional customer service and compassionate, patient-centered care. 

• Excellent organizational and time management skills. 

• Comfort working with patients experiencing complex medical, behavioral health, cognitive, and psychosocial needs. 

• Proficiency using electronic medical records, scheduling systems, Microsoft Office, and multiple technology platforms. 

• Ability to work independently while collaborating effectively with interdisciplinary teams. 

Preferred Qualifications 

• Community Health Worker (CHW) certification or comparable experience. 

• Experience as a Care Navigator or Health Coach. 

• Healthcare outreach, enrollment, or patient engagement experience. 

• Hospital, physician practice, home health, hospice, post-acute, or population health experience. 

• Experience scheduling healthcare appointments. 

• Familiarity with Medicare Advantage or other value-based care programs. 

• Experience working in startup or rapidly growing healthcare organizations. 

• Bilingual language skills. 

Schedule and Work Style 

Employment Type: Full-Time, Hourly 

Location: Primarily onsite in the Rockville, Maryland region 

Schedule: Monday through Friday, 8:00 AM–5:00 PM 

This role works onsite within an assigned hospital while collaborating closely with Avail Health’s virtual interdisciplinary care team through daily huddles, secure communication platforms, and coordinated workflows. 

Compensation and Perks 

Hourly Rate: $25.00–$31.25 per hour, commensurate with experience. 

Avail Health provides: 

• Medical, dental, and vision insurance with 100% employee premium coverage 

• Direct Primary Care (DPC) membership for employees and eligible dependents 

• HSA contributions 

• Life and disability insurance 

• 401(k) with 2% employer match 

• 15 days of paid time off, increasing with tenure 

• 8 company holidays plus 1 floating holiday 

• Technology and equipment provided 

About Avail Health 

Avail Health is a Nurse Practitioner-founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient-provider relationship to deliver innovative, relationship-centered care. As a rapidly growing healthcare organization, we’re building scalable clinical programs that improve outcomes for patients with complex medical and behavioral health needs while creating an exceptional experience for the clinicians and professionals who serve them. For more information visit www.availhealthcare.co 

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