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Position Summary: The Clinical Care Partner 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: 8AM - 5PM - Thursday, Friday, Saturday, Sunday, Monday (Thur - Mon) schedule. Based primarily at Dell Seton and Seton Main - would do remote with Williamson and Hays (Covering central Austin).

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 efficiency

GIP / 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
• Contribute to key performance indicators including:
  • Hospital Length of Stay (Observed-to-Expected Ratio)
  • Hospital Readmission Rates
  • Hospital Mortality Rates
  • Timely Initiation of Care
  • Referral-to-Admit Rate
  • 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

Education and/or Experience:

Certifications, Licenses, and Registrations

• Required: Active and unencumbered RN, LMSW, LCSW, or LICSW licensure. Current CPR certification. Compliance with all JV hospital partner occupational health requirements.

Education

• Required: Associate’s degree in Nursing, Health Sciences, or related field. Alternatively, equivalent degree and healthcare experience.
• Preferred: Bachelor’s degree in nursing, Health Sciences, or related field.

Experience

• Required: None
• Preferred: 2–3 years of experience in care coordination, discharge planning, or healthcare services. Hospital, home health, hospice, or post-acute care experience. Experience working with EMR systems (ie: Epic) and referral platforms.

Skills

• Language Skills: Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, teammates, patients, families, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Ability to manage multiple projects simultaneously and meet deadlines. Ability to design accessible and inclusive learning experiences for a diverse workforce.

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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