Clinical Care Partner III

Compassus•Nashville, TN

4d•Onsite

About The Position

The Weekend Float Clinical Care Partner coordinates safe, efficient, patient-centered transitions of care for hospitalized patients. The 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. It 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 position involving bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. This full-time weekend float role covers Friday through Monday at Ascension St. Thomas Midtown and Ascension St. Thomas West Hospitals in Nashville. The schedule may consist of four 10-hour shifts or four 8-hour shifts. The role requires an RN, LCSW, or LMSW, with applicable licensure and current CPR certification.

Requirements

An accredited degree in nursing (RN) or a Master of Social Work (LCSW or LMSW).
Active, unencumbered Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or Speech Therapist licensure, or an equivalent designation applicable to regulatory requirements in the state of employment.
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 articulate and embrace hospice philosophy.
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 appropriate home-based and post-acute care services using clinical, functional, psychosocial, and environmental factors.
Review inpatient referrals, prioritize patients using clinical judgment and predictive analytics, and collaborate with physicians and care teams on level-of-care decisions.
Identify patients appropriate for value-based post-acute care services.
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 handoffs to post-acute providers.
Educate patients and families about post-acute options, care expectations, and available services, supporting informed choice and shared decision-making.
Educate hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care principles, and appropriate site-of-care selection.
Serve as a liaison between hospital teams and post-acute providers and maintain relationships with physicians, case management, nursing teams, and discharge planners.
Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions; strengthen referral 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 designated systems and use clinical decision-support and predictive analytics tools.
Track referrals, outcomes, and transitions across systems.
Support value-based care performance goals and key performance indicators, including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, and referral quality and documentation accuracy.
Participate in quality improvement and workflow optimization initiatives and support organizational efforts to improve post-acute network performance and patient outcomes.