Clinical Care Partner II

Compassus•Olympia, WA

4d•$34 - $52•Onsite

About The Position

The Clinical Care Partner II 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 ensuring patients receive the right 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 clinical, functional, psychosocial, and environmental factors; coordinates individualized discharge and transition plans; arranges post-acute services; educates patients, families, and hospital stakeholders; and maintains relationships with hospital and post-acute providers. Depending on the service line, it may coordinate hospice and General Inpatient (GIP) evaluations and transitions. The role documents care coordination activities, uses electronic medical records and referral systems, and supports performance goals and quality improvement initiatives related to length of stay, readmissions, mortality, timely initiation of care, referral conversion, and documentation quality. The schedule is 8 a.m.–5 p.m., either Sunday–Thursday or Tuesday–Saturday. Required education is a BSW or MSW in Social Work, Health Sciences, or a related field. No experience is required; 2–3 years of relevant experience is preferred. Current CPR certification and compliance with JV hospital partner occupational health requirements are required.

Requirements

BSW or MSW in Social Work, Health Sciences, or a related field.
Current CPR certification.
Compliance with all JV 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.
Ability to present information effectively 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 manage multiple projects simultaneously and meet deadlines.
Ability to design accessible and inclusive learning experiences for a diverse workforce.
Ability to articulate and embrace hospice philosophy.

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 electronic medical record 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 tools, 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 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 on post-acute care options, care expectations, and available services, 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.
Serve as a liaison between hospital teams and post-acute providers and maintain relationships with physicians, case management, nursing teams, and discharge planners.
Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions, and strengthen referral network partnerships.
When applicable to the service line, identify patients appropriate for hospice or GIP, coordinate hospice evaluations and admissions, support end-of-life transitions, and ensure alignment with eligibility and physician certification requirements.
Document care coordination activities accurately and timely in the electronic medical record and manage referrals through designated hospital and post-acute referral systems.
Use clinical decision-support tools and predictive analytics platforms, and track referrals, outcomes, and transitions across systems.
Support value-based environment performance goals and care coordination strategy, including key performance indicators for length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, 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.