RN Clinical Care Partner III

Compassus•Portland, OR

3d•$53 - $74•Onsite

About The Position

The Clinical Care Partner III 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. Its focus is improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive appropriate care in the right setting and at the right time. This is an in-person position requiring bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. The role evaluates clinical, functional, psychosocial, and environmental factors; reviews and prioritizes inpatient referrals using clinical judgment and predictive analytics; coordinates individualized discharge and transition plans; arranges post-acute services; and ensures accurate handoffs. It educates patients, families, hospital staff, and clinical stakeholders about post-acute options and pathways, and serves as a liaison between hospital teams and post-acute providers. Where applicable, it coordinates hospice and General Inpatient (GIP) evaluations, eligibility determinations, and admissions, including patient-centered end-of-life transitions. The Clinical Care Partner III documents activities in the electronic medical record, manages referrals through designated systems, uses clinical decision-support and predictive analytics tools, tracks referral outcomes, and supports value-based care goals, quality improvement, and workflow optimization. The schedule is weekdays, day shift, 24 hours per week. The role floats between Providence Milwaukie, Providence Willamette Falls, and Providence Newberg.

Requirements

An accredited degree in nursing (RN), Master of Social Work (LCSW), or a master's degree in Speech Language Pathology.
An active, unencumbered RN, LCSW, or Speech Therapist license or equivalent designation applicable to regulatory requirements in the state of employment.
Current CPR certification.
Compliance with all joint venture 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, and to present information and respond to questions from leaders, teammates, patients, families, and external parties.
Strong written and verbal communication skills and 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 perform regular standing, walking, and manual dexterity tasks and lift or move objects up to 50 pounds.
Ability to meet visual acuity demands, including 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 electronic medical record systems such as Epic and referral platforms.
Articulates and embraces hospice philosophy.

Responsibilities

Evaluate patients for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factors.
Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools.
Collaborate with physicians and care teams on appropriate level-of-care decisions and identify patients appropriate for value-based post-acute 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 about post-acute care options, care expectations, and available services; provide bedside education that supports informed choice and shared decision-making.
Educate hospital staff and clinical stakeholders about 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; 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 hospice evaluations, eligibility determinations, and admissions, and support patient-centered end-of-life transitions.
Document care coordination activities accurately and promptly in the electronic medical record; manage referrals through 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 care performance goals and key performance indicators, including 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 efforts to improve post-acute network performance and patient outcomes.