Care Transitions Specialist

Compassus; Jacksonville (FL); On-site; USD 65,000 - 85,000; Full time

Job summary

Compassus is seeking a Clinical Care Partner to coordinate safe, efficient transitions of care for hospitalized patients and evaluate eligibility for home-based post-acute services. This in-person role requires bedside engagement and close collaboration with physicians, case management, patients, families, and post-acute providers.

You will support discharge planning, arrange home health, hospice, durable medical equipment, and follow-up care, and educate patients and families on options.

Qualifications

• Active RN, LMSW, LCSW, or LICSW licensure and CPR certification.

Responsibilities

• Coordinate safe transitions of care for hospitalized patients.
• Evaluate patients for home-based post-acute care services.
• Discharge planning collaboration with physicians, case management, patients, families, and post-acute providers.
• Coordinate post-acute services including home health, hospice, durable medical equipment, medications, and follow-up care.
• Educate patients and families on post-acute care options and care expectations.
• Participate in interdisciplinary rounds and care coordination discussions.

Skills

Care coordination

Discharge planning

Communication skills

EMR experience (Epic)

Referral platforms

Education

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

Bachelor’s degree in nursing, Health Sciences, or related field

Tools

Epic EMR

Referral platforms

Job description

Compassus is seeking a Clinical Care Partner to coordinate safe, efficient transitions of care for hospitalized patients and evaluate eligibility for home-based post-acute services. This in-person role requires bedside engagement and close collaboration with physicians, case management, patients, families, and post-acute providers.

You will support discharge planning, arrange home health, hospice, durable medical equipment, and follow-up care, and educate patients and families on options.