Senior Care Transitions Coordinator

Ascension at Home; Austin (TX); On-site; USD 70,000 - 110,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Wellness programs

Job summary

Compassus is seeking a Clinical Care Partner III for in-person work to coordinate safe, efficient transitions of care from hospital to home-based settings. You will collaborate with physicians, case management, and post-acute providers to ensure timely discharge planning and appropriate care settings.

The role requires active RN, LCSW, or Speech Therapist licensure and may include 2–3 years of care coordination experience.

Qualifications

• Active RN, LCSW, or Speech Therapist licensure required.
• Preferred: 2–3 years in care coordination or discharge planning.
• Experience with EMR systems (Epic) and referral platforms.

Responsibilities

• Evaluate patients for home-based and post-acute care services based on clinical and psychosocial factors.
• Coordinate timely, safe discharge planning and transitions.
• Educate patients and families on post-acute care options.
• Serve as liaison between hospital teams and post-acute providers.
• Document care coordination activities in the EMR.

Skills

Care coordination

Discharge planning

Interdisciplinary collaboration

Education

Nursing degree (RN) / LCSW / Speech Language Pathology degree

Tools

Epic EMR

Referral platforms

Job description

Compassus is seeking a Clinical Care Partner III for in-person work to coordinate safe, efficient transitions of care from hospital to home-based settings. You will collaborate with physicians, case management, and post-acute providers to ensure timely discharge planning and appropriate care settings.

The role requires active RN, LCSW, or Speech Therapist licensure and may include 2–3 years of care coordination experience.