Care Coordinator RN; Weekdays M-F

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.

We are hiring RN Care Coordinators with hospital experience for day and night shifts. Relocation assistance is available 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. The role integrates and coordinates care facilitation, care progression, and transitional care planning functions.

• Initiate assessment of patients’ chronic disease management needs and psychosocial risk factors based on preliminary screening.
• Partner with PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements for all payers.
• Collaborate with patient, family, physician(s), and care team to establish and support patient’s care progression and discharge plans.
• Meet with physicians and care team routinely to collaborate on timely and efficient patient management.

• Manage all aspects of discharge planning for assigned patients.
• Implement discharge planning timely and provide resources efficiently.
• Meet with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
• Identify and document barriers for timely disposition.
• Ensure and maintain discharge plan consensus with patient/family, physicians, care teams, and payers.
• Respond to referrals for patients’ post-acute needs from physicians and the care team.
• Participate in interdisciplinary rounds to confirm estimated discharge date and recommend best level of care transition at discharge.
• Initiate/facilitate post-acute referrals through departmental processes for timely transition to the next level of care.
• Refer appropriate cases for social work intervention based on departmental protocol.
• Respect cultural or religious beliefs when providing service and continuity of care.

• Collaborate with physicians and care team to facilitate communication regarding patients’ care progression to ensure timely delivery of care.
• Proactively identify delays or obstacles in diagnostics or treatments that may lead to discharge delays.
• Discuss medical necessity of inpatient testing potentially more appropriate in an outpatient setting with physicians.
• Actively work to resolve barriers to discharge and engage or elevate barriers to appropriate leaders for efficient resolution.

• Complete initial clinical/psychosocial assessment and document in medical record.
• Ensure all records are up‑to‑date and documentation is clear and concise.
• Maintain timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners regarding discharge plan.
• Account for and indicate all services arranged/delivered in electronic medical record.
• Track avoidable days and report trends leading to undesired outcomes.

• Complete all initial and ongoing professional competency assessments and mandatory education.
• Support department‑based goals contributing to the success of the organization.
• Serve as a preceptor and/or mentor for student interns (if appropriate).
• Perform other duties as assigned.
• Comply with all Wellstar Health System policies, standards of work, and code of conduct.

May have other duties assigned.

• Associate’s Nursing or Diploma (Nurse) Nursing
• Bachelor’s Nursing – Preferred

• RN – Regular Nurse (Single State) or…