Senior Care Coordination Partner: Discharge & Transitions

Ascension at Home; Indianapolis (IN); On-site; USD 65,000 - 95,000; Full time

Job summary

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate safe, efficient transitions of care for hospitalized patients. This in-person role focuses on discharge planning, home-based care, and collaboration with physicians and care teams to ensure timely, high-quality patient outcomes.

You will educate patients and families, manage referrals, and participate in interdisciplinary rounds. Required RN/LCSW/SLP education with preferred 2–3 years in care coordination.

Qualifications

• Accredited nursing degree, social work master's, or speech pathology master.
• Experience in discharge planning or care coordination preferred.
• Proficient in EMR usage and post-acute care workflows.

Responsibilities

• Coordinate safe discharge planning and transitions of care.
• Evaluate patients for home-based post-acute services and care needs.
• Educate patients and families on post-acute options and care plans.
• Collaborate with physicians, case management, and nursing teams.
• Manage referrals and arrange home health, hospice, and equipment.
• Participate in rounds and care coordination discussions.
• Identify hospice or GIP candidates and assist with admissions.

Skills

Care coordination

Discharge planning

Communication

EMR (Epic)

Collaboration

Education

RN license

LCSW

MS in Speech-Language Pathology

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. This in-person role focuses on discharge planning, home-based care, and collaboration with physicians and care teams to ensure timely, high-quality patient outcomes.

You will educate patients and families, manage referrals, and participate in interdisciplinary rounds. Required RN/LCSW/SLP education with preferred 2–3 years in care coordination.