Discharge & Post-Acute Care Navigator

Ascension At Home; Nashville (TN); On-site; USD 65,000 - 85,000; 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 (RN/LMSW/LCSW) based at Ascension St. Thomas West Hospital for Monday–Friday, 8am–5pm. You will coordinate safe transitions of care for hospitalized patients and support discharge planning with physicians, case management, patients, and families.

This in-person role emphasizes bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.

Qualifications

• Active RN, LMSW, LCSW, or LICSW licensure; CPR certification.
• Associate’s degree in Nursing, Health Sciences, or related field; Bachelor’s preferred.
• 2–3 years in care coordination, discharge planning, or healthcare services preferred.

Responsibilities

• Evaluate patients for home-based and post-acute care services based on clinical factors.
• Coordinate hospital discharge planning and transitions of care.
• Educate patients and families on post-acute options and services.
• Maintain strong relationships with physicians, case management, and discharge planners.
• Identify hospice or GIP candidates and coordinate eligibility and admission.
• Document care coordination activities in the EMR and manage referrals.
• Support care coordination KPIs and improvement initiatives.

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

Ascension at Home, together with Compassus, seeks a Clinical Care Partner (RN/LMSW/LCSW) based at Ascension St. Thomas West Hospital for Monday–Friday, 8am–5pm. You will coordinate safe transitions of care for hospitalized patients and support discharge planning with physicians, case management, patients, and families.

This in-person role emphasizes bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.