Discharge & Post-Acute Care Coordinator

Compassus; Jacksonville (FL); On-site; USD 75,000 - 95,000; Full time

Job summary

Ascension at Home together with Compassus is seeking a Clinical Care Partner III to coordinate patient-centered transitions of care for hospitalized patients. This in-person role focuses on discharge planning, collaboration with physicians and care teams, and arranging post-acute services to ensure safe, timely care in the right setting.

The position emphasizes value-based care, patient education, and engagement with families to support informed decisions and quality outcomes across the care

Qualifications

• RN, LCSW, or Speech-Language Pathology master's degree required.
• Experience in care coordination or discharge planning preferred.
• Hospital, home health, hospice, or post-acute care experience is desirable.

Responsibilities

• Coordinate safe, efficient transitions of care and discharge planning.
• Evaluate patients for appropriate home-based and post-acute care services.
• Collaborate with physicians and care teams to support level-of-care decisions.
• Arrange post-acute services including home health, hospice, and DME.
• Educate patients and families on post-acute care options and pathways.

Skills

Care coordination

Discharge planning

Communication skills

Interdisciplinary collaboration

Education

RN

Master of Social Work (LCSW)

Master's in Speech-Language Pathology

Tools

Epic EMR

Referral platforms

Job description

Ascension at Home together with Compassus is seeking a Clinical Care Partner III to coordinate patient-centered transitions of care for hospitalized patients. This in-person role focuses on discharge planning, collaboration with physicians and care teams, and arranging post-acute services to ensure safe, timely care in the right setting.

The position emphasizes value-based care, patient education, and engagement with families to support informed decisions and quality outcomes across the care