Clinical Care Partner

Company:Ascension at Home together with CompassusPosition Summary: The Clinical Care Partner is responsible for coordinating safe, efficient, and patient-centered transitions of care for hospitalized patients. This role evaluates patients for appropriate post-acute home-based care services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers.The position focuses on improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive the right care in the right setting at the right time. This is an in-person role requiring bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.Position Specific Responsibilities: RN, LCSW or LMSW Required for this role.Referral Evaluation & Clinical AssessmentEvaluate patients for appropriateness for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factorsReview inpatient referrals and prioritize patients using clinical judgment and predictive analytics toolsCollaborate with physicians and care teams to support appropriate level-of-care decisionsIdentify patients appropriate for value-based post-acute care servicesDischarge Coordination & Care TransitionsCoordinate and facilitate timely, safe, and appropriate hospital discharge planningDevelop and implement individualized transition-of-care plans aligned with patient needs and clinical goalsPartner with physicians, advanced practice providers, case management, and nursing teamsArrange post-acute services including home health, hospice, durable medical equipment, medications, and follow-up careEnsure accurate and timely patient handoff to post-acute providersStakeholder EducationEducate patients and families on post-acute care options, care expectations, and available servicesProvide bedside education to support informed patient choice and shared decision-makingEducate hospital staff and clinical stakeholders on post-acute pathways and referral processesSupport understanding of value-based care principles and appropriate site-of-care selectionReferral Source Relationship ManagementServe as liaison between hospital teams and post-acute providers to support timely referrals and placementsMaintain strong relationships with physicians, case management, nursing teams, and discharge plannersParticipate in interdisciplinary rounds, discharge planning meetings, and care coordination discussionsStrengthen referral network partnerships to improve access and placement efficiencyGIP / Hospice-Specific Coordination (if applicable to service line)Identify patients appropriate for hospice and/or General Inpatient (GIP) level of careCoordinate hospice evaluations, eligibility determinations, and admission processesSupport end-of-life transitions with clinical urgency and patient-centered communicationEnsure alignment with hospice eligibility requirements and physician certification processesDocumentation & TechnologyDocument all care coordination activities accurately and timely in the electronic medical recordManage referrals through designated hospital and post-acute referral systemsUtilize clinical decision-support tools and predictive analytics platformsMaintain accurate tracking of referrals, outcomes, and transitions across systemsPerformance, KPIs & StrategySupport VBE performance goals and care coordination strategyContribute to key performance indicators including:Hospital Length of Stay (Observed-to-Expected Ratio)Hospital Readmission RatesHospital Mortality RatesTimely Initiation of CareReferral-to-Admit RateReferral Quality and Documentation AccuracyParticipate in quality improvement and workflow optimization initiativesSupport organizational initiatives to improve post-acute network performance and patient outcomesEducation and/or Experience:EducationRequired: Associate’s degree in Nursing, Health Sciences, or related field. Alternatively, equivalent degree and healthcare experience.Preferred: Bachelor’s degree in nursing, Health Sciences, or related field.ExperienceRequired: NonePreferred: 2–3 years of experience in care coordination, discharge planning, or healthcare services. Hospital, home health, hospice, or post-acute care experience. Experience working with EMR systems (ie: Epic) and referral platforms.SkillsLanguage Skills: Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, teammates, patients, families, and external parties. Strong written and verbal communications.Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Ability to manage multiple projects simultaneously and meet deadlines. Ability to design accessible and inclusive learning experiences for a diverse workforce.Certifications, Licenses, and RegistrationsRequired: Active and unencumbered RN, LMSW, LCSW, or LICSW licensure. Current CPR certification. Compliance with all JV hospital partner occupational health 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 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to positions in our organization.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, national origin, genetics, disability, age, or veteran status.#LI-KM1Build a Rewarding Career with CompassusAt 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 MattersWe’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.SummaryLocation: Jacksonville, FLType: Full timePosted: 2026-09-16Country: United States of AmericaRequisition: 2026-57114Posting ID: 035c35d533751000b5d8756fdc2e0000