Clinical Care Partner III

Compassus•Olympia, WA

1d•$36 - $54•Onsite

About The Position

The Clinical Care Partner coordinates safe, efficient, 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 appropriate care in the right setting. This is an in-person role requiring 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; and provides education to patients, families, and hospital stakeholders. The Clinical Care Partner also maintains referral relationships, documents activities across electronic and referral systems, and supports value-based care performance and quality-improvement initiatives. Hospice and General Inpatient coordination may be included depending on the service line.

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, and to present information 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 articulate and embrace hospice philosophy.
Ability to manage multiple projects simultaneously and meet deadlines.
Ability to design accessible and inclusive learning experiences for a diverse workforce.
Ability to perform regular standing, walking, and manual-dexterity tasks and to lift and move objects up to 50 pounds.
Visual ability for close and distance vision, color and peripheral vision, depth perception, and adjusting focus.

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 electronic medical record systems such as Epic and referral platforms.

Responsibilities

Evaluate patients for home-based and post-acute care services using 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 care options, expectations, and available services, supporting informed choice and shared decision-making.
Educate hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care principles, and site-of-care selection.
Liaise between hospital teams and post-acute providers to support timely referrals and placements, and maintain relationships with relevant clinical 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.
When applicable, identify patients appropriate for hospice or General Inpatient level of care; coordinate evaluations, eligibility determinations, and admissions; and support end-of-life transitions.
Document care-coordination activities accurately and promptly in the electronic medical record and manage referrals through designated systems.
Use clinical decision-support tools and predictive analytics platforms, and track referrals, outcomes, and transitions across systems.
Support value-based excellence performance goals and care-coordination strategy, including performance indicators related to 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.