Weekend Discharge & Care Transitions Nurse

Ascension At Home; Indianapolis (IN); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive pay

Tuition reimbursement

Flexible time off

Job summary

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate transitions of care for hospitalized patients. Role involves bedside engagement, discharge planning workflows, and collaboration with physicians, case management, and post-acute providers.

Responsibilities include evaluating home-based care suitability, coordinating post-discharge services, educating patients and families, and supporting value-based care initiatives in a fast-paced environment.

Qualifications

• Required: An accredited degree in nursing (RN), LCSW, or Master’s in Speech-Language Pathology.
• Preferred: 2–3 years in care coordination, discharge planning, or post-acute care.

Responsibilities

• Evaluate patients for home-based and post-acute care eligibility.
• Review inpatient referrals and prioritize using clinical judgment.
• Collaborate with physicians and care teams for appropriate level-of-care decisions.
• Coordinate timely, safe hospital discharges and transition plans.
• Educate patients and families on post-acute options and services.
• Partner with post-acute providers and hospice teams.
• Document activities in the EMR and track referrals.

Skills

Care coordination

Discharge planning

Communication

Hospice knowledge

Education

RN

LCSW

Speech-language pathology (MSLP)

Tools

Epic

Job description

Ascension at Home together with Compassus seeks a Clinical Care Partner III to coordinate transitions of care for hospitalized patients. Role involves bedside engagement, discharge planning workflows, and collaboration with physicians, case management, and post-acute providers.

Responsibilities include evaluating home-based care suitability, coordinating post-discharge services, educating patients and families, and supporting value-based care initiatives in a fast-paced environment.