RN Clinical Care Partner III

Compassus • Portland, OR

5d • $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. The position focuses on improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive appropriate care in the right setting. It is an in-person role involving bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. The role floats between St Vincent Hospital and Providence Portland Hospital and is scheduled for 24 hours per week on weekdays during the day shift.

Requirements

• An accredited degree in nursing (RN), Master of Social Work (LCSW), or a master's degree in Speech Language Pathology.
• Active, 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(s).
• 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 the 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.

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 services using 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.
• 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 options, care 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, and appropriate site-of-care selection.
• Act 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, and strengthen referral partnerships.
• When applicable, identify patients appropriate for hospice or General Inpatient (GIP) care; coordinate hospice evaluations, eligibility determinations, and admissions.
• Support end-of-life transitions through clinically timely, 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 track referrals, outcomes, and transitions.
• Use clinical decision-support tools and predictive analytics platforms.
• Support value-based enterprise (VBE) performance goals and care coordination strategy, 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 and support initiatives to improve post-acute network performance and patient outcomes.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Employer-paid life insurance
• Employer-paid disability insurance
• 401(k) retirement plan
• Paid time off
• Paid holidays
• Mileage reimbursement
• Continuing education support
• Employee Assistance Program
• Career development, leadership pathways, mentorship, and professional development
• Flexible time off
• Tuition reimbursement
• Wellness programs
• Recognition programs

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level