Care Transitions Partner – Discharge & Post-Acute Care

Ascension at Home; Jacksonville (FL); On-site; USD 60,000 - 75,000; Full time

Benefits offered by this job

Tuition reimbursement

Wellness programs

Competitive pay

Flexible time off

Job summary

Ascension at Home together with Compassus is seeking a Clinical Care Partner to coordinate safe, efficient hospital-to-home transitions. The role collaborates with physicians, case management, and post-acute providers to ensure timely discharge planning and the right care setting.

Responsibilities include evaluating patient suitability for home-based services, coordinating post-acute care, educating patients and families, and ensuring accurate handoffs to post-acute partners.

Qualifications

• RN, LMSW or LCSW licensure required (active and unencumbered).
• Experience in care coordination, discharge planning, or post-acute care preferred.
• Experience with EMR systems (Epic) and post-acute referrals preferred.

Responsibilities

• Evaluate patients for home-based and post-acute care services using clinical and social factors.
• Coordinate timely hospital discharge planning and post-acute service arrangements.
• Educate patients and families on post-acute options and care expectations.
• Collaborate with physicians, case management, nursing, and post-acute providers.
• Support accuracy of referrals and handoffs across systems.

Skills

RN

LMSW/LCSW

EMR (Epic)

Communication skills

Education

Associate’s degree in Nursing, Health Sciences, or related field

Bachelor’s degree preferred

Tools

Epic EMR

Referral platforms

Job description

Ascension at Home together with Compassus is seeking a Clinical Care Partner to coordinate safe, efficient hospital-to-home transitions. The role collaborates with physicians, case management, and post-acute providers to ensure timely discharge planning and the right care setting.

Responsibilities include evaluating patient suitability for home-based services, coordinating post-acute care, educating patients and families, and ensuring accurate handoffs to post-acute partners.