Clinical Care Partner at LE0400 Compassus Providence Holdings, LLC — Austin, TX

Company:

Position Specific Responsibilities: Social Worker preferred or this role. RN also considered. Monday - Friday, 8AM - 5PM with occasional holiday rotation. Nursing home or hospice referral experience strongly preferred. Hospital case management / discharge experience desired. Based at Seton Main.

• 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

• 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

• 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.

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The Compassus Advantage

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.