Clinical Care Partner - LPN or Social Worker Required

About the job

Providence at Home with Compassus is hiring a full-time clinical care partner in Spokane, Washington, to coordinate safe, timely transitions of care for hospitalized patients. The role evaluates patients for home-based and post-acute care and supports discharge planning together with physicians, case managers, patients, families and post-acute providers; it is an in-person role that involves work at the bedside.

What you'll do

• Evaluate hospitalized patients for home-based and post-acute care based on clinical, functional, psychosocial and environmental factors, including those suited to value-based post-acute services
• Review and prioritize inpatient referrals using clinical judgment and predictive analytics tools, and work with physicians and care teams on level-of-care decisions
• Coordinate timely, safe discharge planning and build individualized transition-of-care plans that fit patient needs and clinical goals, partnering with physicians, advanced practice providers, case management and nursing
• Arrange post-acute services, such as home health, hospice, medications, durable medical equipment and follow-up care, and hand patients off to post-acute providers accurately and on time
• Educate patients and families at the bedside on post-acute options, care expectations and services so they can make informed, shared decisions
• Teach hospital staff and clinical stakeholders about post-acute pathways, referral processes, value-based care principles and choosing the right site of care
• Act as the link between hospital teams and post-acute providers, keep strong ties with discharge planners, physicians, case management and nursing teams, join interdisciplinary rounds and discharge planning meetings, and strengthen referral network partnerships
• When it applies to the service line, identify patients for hospice or General Inpatient (GIP) care, coordinate hospice evaluations, eligibility and admissions within eligibility and physician certification rules, and support end-of-life transitions
• Document all care coordination accurately and promptly in the electronic medical record, manage referrals in hospital and post-acute referral systems, use decision-support and predictive analytics tools, and track referrals, outcomes and transitions
• Support VBE performance goals and key measures such as timely initiation of care, hospital length of stay, readmission and mortality rates, the referral-to-admit rate, and referral quality and documentation accuracy, plus quality improvement work

What you need

• An associate degree in nursing, health sciences or a related field, or an equivalent degree plus health care experience
• The posting's license list calls for an active, unencumbered RN, LMSW, LCSW or LICSW license, while its title asks for an LPN or social worker
• Current CPR certification
• Meeting all occupational health requirements of the JV hospital partner
• No prior experience is required
• Able to analyze and interpret what you read in clinical documentation, professional journals, technical procedures and government regulations, and to write reports, business letters and procedure manuals
• Able to present information and answer questions from leaders, teammates, patients, families and outside parties, with strong written and verbal communication
• Able to understand, read, write and speak English, and to explain and embrace the hospice philosophy
• Able to manage several projects at once and meet deadlines, and to design accessible, inclusive learning experiences for a diverse workforce
• Regular standing and walking, manual dexterity, and lifting and moving objects of up to 50 pounds
• Visual requirements: depth perception, peripheral and color vision, distance and close vision, and the ability to adjust focus

Preferred

• A bachelor's degree in nursing, health sciences or a related field
• Two to three years of care coordination, discharge planning or health care services experience
• Hospital, home health, hospice or post-acute care experience
• Experience with EMR systems such as Epic and with referral platforms

Schedule

• Full-time

Benefits

• Flexible time off
• Tuition reimbursement
• Wellness programs
• Leadership pathways, mentorship and personalized professional development
• Recognition programs