Clinical Care Partner

Compassus • Pensacola, FL

1d • Onsite

About The Position

The Clinical Care Partner 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 care in the right setting at the right time. This is an in-person role involving bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.

The position evaluates referrals using clinical, functional, psychosocial, and environmental factors; coordinates individualized discharge and transition plans; educates patients, families, and hospital stakeholders; and serves as a liaison between hospital teams and post-acute providers. Depending on the service line, the role may also coordinate hospice and General Inpatient (GIP) evaluations and transitions. The Clinical Care Partner documents care coordination activity, uses electronic medical records and referral and decision-support systems, and supports performance goals, quality improvement, and post-acute network strategy.

Requirements

• Associate’s degree in Nursing, Health Sciences, or a related field; alternatively, an equivalent degree and healthcare experience.
• Active and unencumbered RN, LMSW, LCSW, or LICSW licensure.
• Current CPR certification.
• Compliance with all JV 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.
• Strong written and verbal communication skills, including the ability to present information and respond to questions from leaders, teammates, patients, families, and external parties.
• 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

• Bachelor’s degree in Nursing, Health Sciences, or a related field.
• 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 services based on 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, available services, and shared decision-making.
• Educate hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care, and appropriate site-of-care selection.
• Serve as a liaison between hospital teams and post-acute providers, maintain stakeholder relationships, and participate in interdisciplinary rounds and discharge planning discussions.
• Strengthen referral network partnerships to improve access and placement efficiency.
• When applicable, identify patients appropriate for hospice or GIP care and coordinate evaluations, eligibility determinations, admissions, and end-of-life transitions.
• Ensure hospice transitions align with eligibility requirements and physician certification processes.
• 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 and predictive analytics tools.
• 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 efforts to improve post-acute network performance and patient outcomes.

Benefits

• Competitive pay.
• Flexible time off.
• Tuition reimbursement.
• Wellness programs.
• Career development, including leadership pathways, mentorship, and personalized professional development.
• Recognition programs.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree