Clinical Care Partner III

Compassus•Nashville, TN

4d•Onsite

About The Position

The Float Clinical Care Partner III coordinates safe, efficient, patient-centered transitions of care for hospitalized patients. The role evaluates patients for appropriate post-acute home-based services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers. It aims to improve patient outcomes, reduce length of stay and readmissions, and ensure patients receive the right care in the right setting at the right time. This is an in-person, full-time float role with a Monday–Friday, 8:00 a.m.–5:00 p.m. schedule. The position covers Ascension St. Thomas Midtown and Ascension St. Thomas West Hospitals in Nashville and Ascension St. Thomas Rutherford in Murfreesboro. The role starts at Ascension St. Thomas Rutherford before transitioning to a full-time float role.

Requirements

An accredited degree in nursing (RN), a Master of Social Work (LCSW), or a master’s degree in Speech Language Pathology.
Active and unencumbered Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Speech Therapist licensure or equivalent designation applicable to state regulatory requirements.
Current CPR certification.
Compliance with all joint venture hospital partner occupational health requirements.
Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, and governmental regulations.
Ability to write reports, business correspondence, and procedure manuals, and to present information and respond to questions from leaders, teammates, patients, families, and external parties.
Strong written and verbal communication skills; ability to understand, read, write, and speak English.
Ability to manage multiple projects simultaneously and meet deadlines.
Ability to design accessible and inclusive learning experiences for a diverse workforce.

Nice To Haves

Two to three years of experience in care coordination, discharge planning, or healthcare services.
Hospital, home health, hospice, or post-acute care experience.
Experience with electronic medical record systems such as Epic and referral platforms.

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 on appropriate level-of-care decisions and identify patients appropriate for value-based post-acute care.
Coordinate timely, safe, and appropriate hospital discharge planning and develop individualized transition-of-care plans.
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 handoffs to post-acute providers.
Educate patients and families about post-acute care options, care expectations, available services, and informed choice.
Educate hospital staff and clinical stakeholders on post-acute pathways, referral processes, value-based care principles, and site-of-care selection.
Liaise between hospital teams and post-acute providers to support timely referrals and placements.
Maintain relationships with physicians, case management, nursing teams, and discharge planners; participate in interdisciplinary rounds and care coordination discussions.
Strengthen referral network partnerships to improve access and placement efficiency.
When applicable, identify patients appropriate for hospice or General Inpatient (GIP) care; coordinate hospice evaluations, eligibility determinations, and admissions.
Support end-of-life transitions with clinical urgency and patient-centered communication, ensuring alignment with hospice eligibility and physician certification requirements.
Document care coordination activities accurately and promptly in the electronic medical record.
Manage referrals through hospital and post-acute referral systems and use clinical decision-support tools and predictive analytics platforms.
Track referrals, outcomes, and transitions across systems.
Support value-based episode performance goals and care coordination strategy, including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, referral quality, and documentation accuracy.
Participate in quality improvement and workflow optimization initiatives and support efforts to improve post-acute network performance and patient outcomes.