Clinical Care Partner

Company:
Providence at Home with Compassus

Position Summary:

The Clinical Care Partner I 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.

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

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

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

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

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

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

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

Education Required:

Associate’s degree in Nursing, Health Sciences, or related field. Preferred:
Bachelor’s degree in nursing, Health Sciences, or related field.

Experience

Required:

None Preferred: 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.

Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations. Ability to write reports, business…