Senior Care Coordination & Discharge Partner

Compassus; Indianapolis (IN); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Wellness programs

Job summary

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate safe, efficient transitions of care for hospitalized patients. You will evaluate patients for home-based services and support discharge planning with physicians, case management, patients, families, and post-acute providers.

This in-person role emphasizes bedside engagement, interdisciplinary collaboration, and active participation in discharge workflows to reduce length of stay and readmissions while

Qualifications

• Active and unrestricted RN, LCSW, or speech-language pathologist licensure suitable for state employment.
• Experience in care coordination or discharge planning preferred.
• Excellent written and verbal communication and teamwork abilities.

Responsibilities

• Referral Evaluation & Clinical Assessment: assess suitability for home-based services.
• Discharge Coordination & Care Transitions: coordinate timely, safe plans.
• Stakeholder Education: inform patients, families, and staff.
• Referral Source Relationship Management: maintain physician and team relationships.
• GIP/Hospice Coordination: coordinate appropriate levels of care when applicable.
• Documentation & Technology: record care activities in EMR and referral systems.
• Performance, KPIs & Strategy: support post-acute network metrics and quality.

Skills

Discharge planning

Care coordination

Clinical assessment

Communication skills

Education

RN license

MSW or SLP degree

Tools

Epic EMR

Referral platforms

Job description

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate safe, efficient transitions of care for hospitalized patients. You will evaluate patients for home-based services and support discharge planning with physicians, case management, patients, families, and post-acute providers.

This in-person role emphasizes bedside engagement, interdisciplinary collaboration, and active participation in discharge workflows to reduce length of stay and readmissions while