Clinical Care Partner III

Position Summary

Company: Ascension at Home together with Compassus The Float Clinical Care Partner III 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, LMSW required for this role. This is a Full-time Float role, Monday - Friday, 8am - 5pm work schedule. Role will cover (float) needs for Ascension St. Thomas Midtown and Ascension St. Thomas West Hospitals in Nashville and Ascension St. Thomas Rutherford in Murfreesboro. Role will start at Ascension St. Thomas Rutherford (Murfreesboro) and then transition to full time float role.

Referral Evaluation & Clinical Assessment

Evaluate patients for appropriateness for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factors Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools Collaborate with physicians and care teams to support appropriate level-of-care decisions Identify patients appropriate for value-based post-acute care services

Discharge Coordination & Care Transitions

Coordinate and facilitate timely, safe, and appropriate hospital discharge planning Develop and implement individualized transition-of-care plans aligned with patient needs and clinical goals Partner with physicians, advanced practice providers, case management, and nursing teams Arrange post-acute services including home health, hospice, durable medical equipment, medications, and follow-up care Ensure accurate and timely patient handoff to post-acute providers

Stakeholder Education

Educate patients and families on post-acute care options, care expectations, and available services Provide bedside education to support informed patient choice and shared decision-making Educate hospital staff and clinical stakeholders on post-acute pathways and referral processes Support understanding of value-based care principles and appropriate site-of-care selection

Referral Source Relationship Management

Serve as liaison between hospital teams and post-acute providers to support timely referrals and placements Maintain strong relationships with physicians, case management, nursing teams, and discharge planners Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions Strengthen referral network partnerships to improve access and placement efficiency

GIP / Hospice-Specific Coordination (if applicable to service line)

Identify patients appropriate for hospice and/or General Inpatient (GIP) level of care Coordinate hospice evaluations, eligibility determinations, and admission processes Support end-of-life transitions with clinical urgency and patient-centered communication Ensure alignment with hospice eligibility requirements and physician certification processes

Documentation & Technology

Document all care coordination activities accurately and timely in the electronic medical record Manage referrals through designated hospital and post-acute referral systems Utilize clinical decision-support tools and predictive analytics platforms Maintain accurate tracking of referrals, outcomes, and transitions across systems

Performance, KPIs & Strategy

Support VBE performance goals and care coordination strategy Contribute to key performance indicators including: Hospital Length of Stay (Observed-to-Expected Ratio) Hospital Readmission Rates Hospital Mortality Rates Timely Initiation of Care Referral-to-Admit Rate Referral Quality and Documentation Accuracy Participate in quality improvement and workflow optimization initiatives Support organizational initiatives to improve post-acute network performance and patient outcomes Education and/or Experience

Education Required

An accredited degree in nursing (RN), Master of Social Work (LCSW), or Master’s degree in Speech Language Pathology.

Experience Required

None

Preferred

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.

Skills Language 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 Registrations Required

Active and unencumbered Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Speech Therapist licensure or equivalent designation applicable to regulatory requirements for the state of employment. 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.

Company Culture & Diversity

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.

Compassus Advancement

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.

• 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.

Additional Compassus Information

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.