Clinical Care Partner

Compassus; Edmonds (WA); On-site; USD 129,946,000 - 194,877,000; Full time

Job summary

Providence at Home with Compassus is seeking a Clinical Care Partner to coordinate safe transitions of care for hospitalized patients at Providence Swedish Edmonds Hospital. This in-person role focuses on discharge planning, post-acute home-based services, and collaboration with physicians, case management, and families to ensure appropriate care settings.

You will evaluate referrals, arrange post-acute services, and educate patients and families on options, value-based pathways, and

Qualifications

• Associate’s degree in Nursing, Health Sciences, or related field is required.
• Preferred: Bachelor’s degree in nursing, Health Sciences, or related field.
• Active RN, LMSW, LCSW, or LICSW licensure with CPR certification.
• Experience with EMR systems (Epic) and post-acute referrals is preferred.

Responsibilities

• Coordinate safe transitions of care for hospitalized patients.
• Evaluate patients for home-based post-acute care services.
• Collaborate with physicians, case management, and post-acute providers.
• Coordinate discharge planning and handoffs to post-acute services.
• Educate patients and families on post-acute options.

Skills

Care coordination

Discharge planning

Communication

Team collaboration

Education

Associate’s degree in Nursing, Health Sciences, or related field

Bachelor’s degree in nursing, Health Sciences, or related field

Tools

Epic EMR

Referral platforms

Job description

Company: Providence at Home with Compassus Schedule: Monday - Friday (with weekend rotation), 8am-5pm Location: Providence Swedish Edmonds Hospital

Position Summary

The Clinical Care Partner is responsible for coordinating safe, efficient, and patient-centered transitions of care for hospitalized patients. This 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. The position focuses on improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive the right care in the right setting at the right time. This is an in-person role requiring bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows.

Position Specific Responsibilities

Referral Evaluation & Clinical Assessment

• Evaluate patients for appropriateness 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 to support appropriate level-of-care decisions
• Identify patients appropriate for value-based post-acute care services

Discharge Coordination & Care Transitions

• Coordinate and facilitate timely, safe, and appropriate hospital discharge planning
• Develop and implement 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 handoff to post-acute providers

Stakeholder Education

• Educate patients and families on post-acute care options, care expectations, and available services
• Provide bedside education to support informed patient choice and shared decision-making
• Educate hospital staff and clinical stakeholders on post-acute pathways and referral processes
• Support understanding of value-based care principles and appropriate site-of-care selection

Referral Source Relationship Management

• Serve as liaison between hospital teams and post-acute providers to support timely referrals and placements
• Maintain strong 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

GIP / Hospice-Specific Coordination (if applicable to service line)

• Identify patients appropriate for hospice and/or General Inpatient (GIP) level of care
• Coordinate hospice evaluations, eligibility determinations, and admission processes
• Support end-of-life transitions with clinical urgency and patient-centered communication
• Ensure alignment with hospice eligibility requirements and physician certification processes

Documentation & Technology

• Document all care coordination activities accurately and timely in the electronic medical record
• Manage referrals through designated hospital and post-acute referral systems
• Utilize clinical decision-support tools and predictive analytics platforms
• Maintain accurate tracking of referrals, outcomes, and transitions across systems

Performance, KPIs & Strategy

• Support VBE performance goals and care coordination strategy
• Contribute to key performance indicators including: Hospital Length of Stay (Observed-to-Expected Ratio)
• Hospital Readmission Rates
• Hospital Mortality Rates
• Timely Initiation of Care Referral-to-Admit Rate
• Referral Quality and Documentation Accuracy
• Participate in quality improvement and workflow optimization initiatives
• Support organizational initiatives to improve post-acute network performance and patient outcomes

Education and/or Experience

Education Required

Associate’s degree in Nursing, Health Sciences, or related field. Alternatively, equivalent degree and healthcare experience.

Preferred Education

Bachelor’s degree in nursing, Health Sciences, or related field.

Experience Required

None

Preferred Experience

2–3 years of experience in care coordination, discharge planning, or healthcare services. Hospital, home health, hospice, or post-acute care experience. Experience working with EMR systems (ie: Epic) and referral platforms.

Skills

Language Skills

Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, teammates, patients, families, and external parties. Strong written and verbal communications.

Other Skills and Abilities

Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Ability to manage multiple projects simultaneously and meet deadlines. Ability to design accessible and inclusive learning experiences for a diverse workforce.

Certifications, Licenses, and Registrations Required

Active and unencumbered RN, LMSW, LCSW, or LICSW licensure. Current CPR certification. Compliance with all JV hospital partner occupational health requirements.

Physical Demands and Work Environment

The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

Diversity, Equity, and Inclusion

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Compensation

Compensation Range: $45.35 - $68.01 hourly

Build a Rewarding Career with Compassus

At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others. Your Career Journey Matters We’re dedicated to helping you grow and succeed. Whether you’re pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.

The Compassus Advantage

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

Ready to Join?

At Compassus, your career is more than a job—it’s an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.

About Compassus

Compassus provides a continuum of integrated home-based services including home health, home infusion, palliative and hospice care. Thousands of teammates and hundreds of access points nationwide provide high-quality care and manage patients’ advanced illnesses in partnership with health systems and long-term care partners. The Compassus Care for who I am culture reflects its unique care delivery model, which focuses on each person as an individual as well as a patient, to improve their quality of life in a meaningful way.

Learn more at compassus.com or follow @Compassus on Facebook, LinkedIn, Instagram or Twitter.