Care Coordination RN

Join to apply for the Care Coordination RN- FT Days role at Wellstar Health System
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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.

Day (United States of America)

Care coordination experience required.

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.

• Based on preliminary screening, initiates assessment of chronic disease management needs and psychosocial risk factors and availability of resources for 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, physician(s) and other members of the care team to fully establish and support both the patient's care progression and discharge plans.
• Meets with physicians and care team routinely to collaborate on timely and efficient patient management.

• Manages all aspects of discharge planning for assigned patients.
• Implements discharge planning timely and provides resources efficiently.
• 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 patients post‑acute needs from physicians and the care team.
• Participates in Interdisciplinary Rounds to confirm estimated date of discharge and make recommendations for best level of care transition.
• Initiates/facilitates post‑acute referrals through departmental processes for timely transition to the next level of care.
• Recommends cases for social work intervention based on departmental protocol.
• Acknowledges cultural or religious beliefs in providing continuous care.

• Collaborates with physicians and care team to facilitate communication regarding patient care progression to ensure timely delivery of care.
• Proactively identifies delays or obstacles in diagnosis or treatments within the plan of care that may 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 escalates unresolved barriers to appropriate leader for efficient resolution.

• Initial clinical/psychosocial assessment completed and documented in medical record.
• Ensures all records are up‑to‑date and documentation is clear and concise.
• Ensures timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team and community partners as it pertains to the patient’s discharge plan.
• Accounts for and indicates all services arranged/delivered in electronic medical record.
• Tracks avoidable days and reports trends that lead to undesired outcomes.

• Completes all initial and ongoing professional competency assessment, required mandatory education, and…