Ascension Health Transition of Care Partner / Saint Thomas Health / FT Days in Nashville, Tennessee

Additional Job Information

Title: Transition of Care Partner

City, State: Nashville,TN

Location: Saint Thomas West Hospital

Department: Care Management

Additional Job Details: FT Days; Monday-Friday 10:00 AM - 7:30 PM

Job Description

Job Summary:

The Transition of Care Partner coordinates the overall interdisciplinary plan of care for patient, from admission to discharge.


  • Creates plan for care across the continuum, integrating patient/family preferences and values.

  • Monitors patient care through assessments, evaluations and/or patient records.

  • Advocates for resources and removal of barriers.

  • Maintains ongoing dialog with supervisor and other health providers to ensure effective implementation of health plan.

  • Perform an initial assessment within 24 hours of admission focused on immediate short term and transition of care needs to drive expected length of stay and working DRG.

  • Perform initial and ongoing Medicare review and/or insurance authorization and follow process for second level review

  • Collaborate with post-acute care partners to identify high risk of readmission patients and tailor post-acute care planning

  • Focus on communication and coordination of transition of care inclusive of discharge coordination activities including skilled, input rehab and long term acute care

  • Contribute to Mission effectiveness by promoting the spirit embodied within the Mission Statement:Service to the Poor - support the cause of those who lack resources for a reasonable quality of life;Reverence - respect and compassion for the dignity and diversity of life;Integrity - inspiring trust through personal leadership;Wisdom - integrating excellence and stewardship;Creativity - courageous innovation;Dedication - affirming hope and joy in our ministry.



  • Minimum Qualificaiton: One or more of the following:

  • Licensed Registered Nurse credentialed from the Tennessee Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date.

  • Preferred Qualificaiton: BLS Provider credentialed from the American Heart Association (AHA).


  • Minimum Qualificaiton: High school diploma or equivalent required

  • Preferred Qualification: Bachelor's degree preferred

Work Experience:

  • Minimum Qualification: One year of experience required.

How To Apply

How to Apply

If you have any questions about the application process or require a reasonable accommodation to complete the application, please contact the Ascension Health Ministry Service Center at 1-855-562-2824 between the hours of 7:30 a.m. to 8:00 p.m. EST M-F.

Equal Employment Opportunity

Saint Thomas Health Services complies with all applicable federal and state laws prohibiting discrimination in hiring or employment practices on the basis of citizenship, race, color, religion, gender, age, national and ethnic origin, disability, or veteran status.

No question or item on this application for employment is intended to secure information to be used for such discrimination. Information obtained through this application will be used solely to determine qualifications and suitability for employment. This application will be valid for a period of 90 days from date of completion.

Please note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.

E-Verify Statement

Saint Thomas Health participates in the Electronic Employment Verification Program. Please click the E-Verify link below for more information.

E-Verify (link to E-verify site)