Clinical Care Partner
On-siteAustin, Texas, United States
Job Summary
Evaluate patients for home-based and post-acute care services based on clinical, functional, and environmental factors. Coordinate and facilitate timely, safe hospital discharge planning by developing individualized transition-of-care plans and arranging post-acute services including home health, hospice, and durable medical equipment. Educate patients, families, and hospital staff on post-acute pathways and value-based care principles to support informed decision-making. Serve as a liaison between hospital teams and post-acute providers to maintain strong referral networks and optimize placement efficiency. Document all activities accurately in the electronic medical record and track referrals using clinical decision-support tools. Support VBE performance goals by contributing to key indicators such as length of stay, readmission rates, and timely initiation of care.
Required Qualifications
- Active and unencumbered RN, LMSW, LCSW, or LICSW licensure
- Current CPR certification
- Compliance with all JV hospital partner occupational health requirements
- Associate's degree in Nursing, Health Sciences, or related field
- Equivalent degree and healthcare experience (alternative to degree)
- 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
- Ability to understand, read, write, and speak English
- Regular standing, walking, and manual dexterity
- Ability to lift and move objects up to 50 pounds
- Close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus
Desired Qualifications
- Bachelor's degree in nursing, Health Sciences, or related field
- 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
- 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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