Care Transitions Navigator

Compassus; Indianapolis (IN); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive pay

Flexible time off

Tuition reimbursement

Wellness programs

Job summary

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate safe, efficient transitions of care for hospitalized patients. Based at Ascension St.

Vincent Hospital, this in-person role focuses on evaluating patients for home-based post-acute services and facilitating timely discharge planning in collaboration with physicians and care teams. The role emphasizes improving outcomes, reducing readmission rates, and ensuring patients receive the right care at the right

Qualifications

• Must be an RN, LCSW or LMSW.
• Active CPR certification.
• Experience with discharge planning preferred.
• Coordinate transitions of care with physicians, case management and families.

Responsibilities

• Evaluate patients for home-based and post-acute care services.
• Coordinate and facilitate hospital discharge planning.
• Educate patients and families on post-acute care options.
• Maintain relationships with hospital teams and post-acute providers.
• Participate in interdisciplinary rounds and care coordination discussions.

Skills

Communication skills

Discharge planning

Interdisciplinary collaboration

English proficiency

Education

RN degree

LCSW

SLP degree

Tools

Epic EMR

Referral platforms

Job description

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate safe, efficient transitions of care for hospitalized patients. Based at Ascension St.

Vincent Hospital, this in-person role focuses on evaluating patients for home-based post-acute services and facilitating timely discharge planning in collaboration with physicians and care teams. The role emphasizes improving outcomes, reducing readmission rates, and ensuring patients receive the right care at the right