Care Coordinator SW ; Weekday

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift Day (United States of America) 1 Year of Acute Care experience required Care Coordination , Discharge Planning, UM experience Preferred Sign on Bonus and Relocation Assistance for eligible candidates.

The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. The CC RN plans effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.

• Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education
• Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs
• Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers
• Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.
• May have other duties assigned

• Based on preliminary screening of patients, initiates assessment of patient’s chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.
• Partners with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
• Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patient’s care progression and discharge plans..
• 30% Meets with physicians and care team routinely to collaborate on timely and efficient patient management.

• Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.
• Identifies and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.
• Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution

• Manages all aspects of discharge planning for assigned patients.
• Implements discharge planning timely and provides resources in an efficient manner.
• Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
• Identifies and documents barriers for timely disposition.
• Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.
• Responds to referrals for patient’s post-acute needs from physicians and the care team.
• Participates in Interdisciplinary Rounds with the patient’s…