Clinical Care Partner - Weekend Coverage - RN, LMSW or LCSW

Company:

Ascension at Home together with Compassus

Position Summary:

The Clinical Care Partner III is responsible for coordinating safe, efficient, and patient-centered transitions of care for hospitalized patients. This role evaluates patients for appropriate post-acute home-based care services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers.

The position focuses on improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive the right care in the right setting at the right time. This is an in-person role requiring bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.

Position Specific Responsibilities:

This is a full-time weekend role. Schedule must include every Saturday and Sunday coverage, but may be either 5 days/8 hour (Thursday
- Monday, 8am - 5pm) or 4 days/10 hour (Friday
- Monday, 8am - 7pm) schedule. This is NOT a remote role, you MUST reside locally. Coverage for St. Thomas West.

Referral Evaluation & Clinical Assessment Evaluate patients for appropriateness 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

Discharge Coordination & Care Transitions 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

Stakeholder Education 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

Referral Source Relationship Management 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 efficiencyGIP / Hospice-Specific Coordination (if applicable to service line)
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

Documentation & Technology 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

Performance, KPIs & Strategy Support VBE performance goals and care coordination strategy

Contri…