Discharge & Care Transitions Specialist

Ascension At Home; Jacksonville (FL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Enhanced Benefits

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 for hospitalized patients and evaluate post-acute home-based care needs. This in-person role partners with physicians, case management, families, and post-acute providers to support timely discharge planning.

You will focus on reducing length of stay and readmissions, ensuring the right care in the right setting at the right time.

Qualifications

• RN, LCSW, or Speech-Language Pathology degree required from an accredited program.
• Experience in care coordination and discharge planning preferred.
• Familiarity with EMR systems and referral platforms is beneficial.

Responsibilities

• Evaluate patients for home-based and post-acute care needs using clinical and environmental factors.
• Review referrals and prioritize patients using clinical judgment.
• Collaborate with physicians and care teams for level-of-care decisions.
• Coordinate timely, safe discharge planning and transition-of-care plans.
• Educate patients and families on post-acute options and care expectations.
• Maintain referrals and participate in interdisciplinary rounds to improve access.

Skills

Strong communication

English proficiency

Multitasking

Education

RN

LCSW

Speech-Language Pathology degree

Job description

Ascension At Home, together with Compassus, seeks a Clinical Care Partner III to coordinate safe, efficient transitions for hospitalized patients and evaluate post-acute home-based care needs. This in-person role partners with physicians, case management, families, and post-acute providers to support timely discharge planning.

You will focus on reducing length of stay and readmissions, ensuring the right care in the right setting at the right time.