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 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 care in the appropriate setting. This is an in-person position with bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. The position floats between St Vincent Hospital and Providence Portland Hospital and is scheduled for 32 hours per week on weekdays during the day shift. The role assesses patients’ clinical, functional, psychosocial, and environmental needs; coordinates individualized discharge and transition plans; arranges post-acute services; and supports informed patient choice through education. It serves as a liaison between hospital teams and post-acute providers, participates in interdisciplinary planning, and coordinates hospice or General Inpatient hospice services when applicable. The position also documents care coordination, manages referrals through electronic systems, uses clinical decision-support and predictive analytics tools, and supports value-based care performance goals, quality improvement, and workflow optimization.

Requirements

An accredited degree in nursing (RN), a Master of Social Work (LCSW), or a master’s degree in Speech Language Pathology.
Active, unencumbered RN, LCSW, or Speech Therapist licensure, or an equivalent designation applicable to state regulatory requirements.
Current CPR certification.
Compliance with occupational health requirements of JV hospital partners.
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.
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 and walking and use manual dexterity; ability to lift and move objects up to 50 pounds.
Visual abilities 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.
Experience in a hospital, home health, hospice, or post-acute care setting.
Experience with electronic medical record systems such as Epic and referral platforms.
Ability to articulate and embrace 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 suitable for value-based post-acute care services.
Coordinate safe, timely, 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 patient 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 appropriate site-of-care selection.
Act as a liaison between hospital teams and post-acute providers to support timely referrals and placements.
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 to improve access and placement efficiency.
When applicable, identify patients appropriate for hospice or General Inpatient (GIP) care; coordinate hospice evaluations, eligibility determinations, and admissions; support end-of-life transitions; 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 hospital and post-acute referral systems and use clinical decision-support and predictive analytics platforms.
Track referrals, outcomes, and transitions across systems.
Support value-based care performance goals and care coordination strategy, including metrics for hospital length of stay, readmissions, mortality, timely initiation of care, referral-to-admit rate, 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.