Compassus·Santa Rosa, California
Coordinate safe and efficient transitions of care for hospitalized patients by evaluating them for appropriate post-acute home-based services. Collaborate with physicians and interdisciplinary teams to implement individualized care plans and reduce hospital readmissions.
Company: Providence at Home with Compassus
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 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 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.
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. This is a 24-hour work week position supporting Santa Rosa Memorial Hospital, Queen of the Valley Medical Center and Petaluma Valley Hospital. Compensation Range: $43.54 - $65.29 hourly #LI-BS2 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.
Requires an associate's degree in Nursing or Health Sciences and an active RN, LMSW, LCSW, or LICSW license. Preferred candidates have 2-3 years of experience in care coordination or post-acute care and proficiency with EMR systems like Epic.
Market context
California nursing roles often draw steady demand, especially for experienced RNs in procedural and critical care settings. Competition is strongest for candidates who already hold a California RN license, current BLS and ACLS, and recent ICU, ER, or PACU experience. Review the AI-summarized requirements and benefits on this platform to save research time, then confirm your certifications and highlight relevant bedside and procedural experience in your application.