Clinical Care Partner - RN, LCSW or LMSW Required

Compassus•Indianapolis, IN

1d•Onsite

About The Position

The Clinical Care Partner III coordinates safe, efficient, and 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 helping patients receive appropriate care in the right setting. This is an in-person role based at Ascension St. Vincent Hospital, with bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. The position requires an RN, LCSW, or LMSW according to the posting’s title and role summary. The schedule is Monday through Friday, 8 a.m. to 5 p.m., with rotating holiday coverage. The role assesses referrals, coordinates discharge and post-acute services, educates patients, families, and hospital staff, and serves as a liaison between hospital teams and post-acute providers. Where applicable, it also coordinates hospice and General Inpatient (GIP) evaluations and transitions. The Clinical Care Partner documents activities in the electronic medical record, uses referral and decision-support systems, tracks outcomes, and contributes to performance goals and quality improvement initiatives. Compassus describes a culture centered on compassion, respect, appreciation, diversity, equity, and inclusion. The company promotes career development, leadership pathways, mentorship, specialized training, and professional development. It also describes competitive pay, flexible time off, tuition reimbursement, wellness programs, recognition programs, and supportive tools and technologies.

Requirements

An accredited degree in nursing (RN), Master of Social Work (LCSW), or a master’s degree in Speech Language Pathology.
Active and unencumbered RN, 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, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals, and effectively 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.
Ability to perform essential functions involving regular standing, walking, and manual dexterity, and to lift and move objects up to 50 pounds.
Visual acuity including close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

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 EMR systems such as Epic and referral platforms.

Responsibilities

Evaluate patients for home-based and post-acute care 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 services.
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 handoffs to post-acute providers.
Educate patients and families about post-acute care options, care expectations, and available services; provide bedside education supporting informed choice and shared decision-making.
Educate hospital staff and clinical stakeholders on post-acute pathways, referral processes, value-based care principles, and appropriate site-of-care selection.
Liaise between hospital teams and post-acute providers to support timely referrals and placements, 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 network partnerships.
When applicable, identify patients appropriate for hospice or GIP care and 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; use clinical decision-support tools and predictive analytics platforms.
Track referrals, outcomes, and transitions across systems.
Support value-based enterprise performance goals and care coordination strategy, including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rates, and referral quality and documentation accuracy.
Participate in quality improvement and workflow optimization initiatives and support improvements to post-acute network performance and patient outcomes.