Senior Care Transitions Coordinator (RN/LCSW)

Ascension at Home; Indianapolis (IN); On-site; USD 65,000 - 90,000; 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 drives discharge planning with physicians, case management, families, and post-acute providers to ensure the right care at the right time.

The ideal candidate evaluates patients for home-based post-acute services, arranges care, educates patients and families, and supports performance metrics to improve outcomes and reduce

Qualifications

• RN/LCSW/SLP credential required.
• Experience in care coordination or discharge planning preferred.
• Experience with EMR systems (Epic) and referrals.

Responsibilities

• Evaluate patients for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factors.
• Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools.
• Collaborate with physicians and care teams to support appropriate level-of-care decisions.
• Identify patients appropriate for value-based post-acute care services.
• Coordinate and facilitate timely, safe, and appropriate hospital discharge planning.
• Develop and implement individualized transition-of-care plans aligned with patient needs and clinical goals.
• Partner with physicians, advanced practice providers, case management, and nursing teams.
• Arrange post-acute services including home health, hospice, durable medical equipment, medications, and follow-up care.
• Ensure accurate and timely patient handoff to post-acute providers.
• Educate patients and families on post-acute care options, care expectations, and available services.
• Provide bedside education to support informed patient choice and shared decision-making.
• Educate hospital staff and clinical stakeholders on post-acute pathways and referral processes.
• Support understanding of value-based care principles and appropriate site-of-care selection.
• Serve as liaison between hospital teams and post-acute providers to support timely referrals and placements.
• Maintain strong relationships with physicians, case management, nursing teams, and discharge planners.
• Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions.
• Strengthen referral network partnerships to improve access and placement efficiency.
• Identify patients appropriate for hospice and/or General Inpatient (GIP) level of care.
• Coordinate hospice evaluations, eligibility determinations, and admission processes.
• Support end-of-life transitions with clinical urgency and patient-centered communication.
• Ensure alignment with hospice eligibility requirements and physician certification processes.
• Document all care coordination activities accurately and timely in the electronic medical record.
• Manage referrals through designated hospital and post-acute referral systems.
• Utilize clinical decision-support tools and predictive analytics platforms.
• Maintain accurate tracking of referrals, outcomes, and transitions across systems.
• Support VBE performance goals and care coordination strategy.
• Contribute to key performance indicators including Hospital Length of Stay, Readmission Rates, Hospital Mortality Rates, Timely Initiation of Care, Referral-to-Admit Rate, and Referral Quality and Documentation Accuracy.
• Participate in quality improvement and workflow optimization initiatives.
• Support organizational initiatives to improve post-acute network performance and patient outcomes.

Skills

Care coordination

Discharge planning

Clinical collaboration

Communication skills

Education

RN

LCSW

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 drives discharge planning with physicians, case management, families, and post-acute providers to ensure the right care at the right time.

The ideal candidate evaluates patients for home-based post-acute services, arranges care, educates patients and families, and supports performance metrics to improve outcomes and reduce