Clinical Care Partner III

Compassus•Olympia, WA

3d•$42 - $63•Onsite

About The Position

The Clinical Care Partner III coordinates safe, efficient, and patient-centered transitions of care for hospitalized patients. The role assesses patients for appropriate post-acute, home-based services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers. It aims to improve outcomes, reduce length of stay and readmissions, and help patients receive care in the appropriate setting. This is an in-person position involving bedside engagement, interdisciplinary collaboration, and participation in discharge planning workflows. The position evaluates referrals using clinical judgment and predictive analytics, develops individualized transition plans, arranges post-acute services, and educates patients, families, and hospital staff about care options and referral pathways. The Clinical Care Partner serves as a liaison between hospital teams and post-acute providers, participates in interdisciplinary discussions, and supports hospice and General Inpatient (GIP) coordination when applicable. The role also documents care coordination in electronic medical records and referral systems, tracks referrals and transitions, supports value-based care performance goals, and participates in quality improvement and workflow optimization initiatives. The schedule is 8 a.m.–5 p.m., either Sunday–Thursday or Tuesday–Saturday. An accredited nursing degree (RN), Master of Social Work (LCSW), or master’s degree in Speech Language Pathology is required, along with applicable active, unencumbered licensure and current CPR certification.

Requirements

Accredited degree in nursing (RN), Master of Social Work (LCSW), or a master’s degree in Speech Language Pathology.
Active and unencumbered RN, LCSW, or Speech Therapist licensure or equivalent designation applicable to state regulatory requirements.
Current CPR certification.
Compliance with occupational health requirements of the joint-venture hospital partner.
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 present information effectively to 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 lift and move objects up to 50 pounds.
Visual ability for close and distance vision, color and peripheral vision, depth perception, and adjustment of focus.

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 EMR systems such as Epic and referral platforms.

Responsibilities

Evaluate patients for home-based and post-acute services based on 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 on post-acute pathways, referral processes, value-based care principles, and appropriate site-of-care selection.
Act 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; strengthen referral network partnerships.
When applicable, identify patients appropriate for hospice or General Inpatient (GIP) care; coordinate evaluations, eligibility determinations, and admissions.
Support end-of-life transitions with clinical urgency and patient-centered communication, and ensure alignment with hospice eligibility and physician certification requirements.
Document care coordination activities accurately and promptly in the electronic medical record; manage referrals through designated systems and use decision-support and predictive analytics tools.
Track referrals, outcomes, and transitions across systems.
Support value-based care performance goals and contribute to measures including length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, and referral quality and documentation accuracy.
Participate in quality improvement, workflow optimization, and initiatives to improve post-acute network performance and patient outcomes.