Care Coordinator RN; Weekdays M-F @ Cobb Hospital

Work Shift

Day (United States of America)

We have day and night shifts available.

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.

• Assess patients’ chronic disease management needs and psychosocial risk factors based on preliminary screening.
• Partner with the PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements for all payers.
• Collaborate with the patient, family, physicians, and other members of the care team to establish and support 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, implement plans in a timely manner, 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 and maintain discharge plan consensus with all stakeholders.
• Respond to referrals for patients’ post‑acute needs from physicians and the care team.
• Participate in interdisciplinary rounds to confirm estimated date of discharge and recommend best level of care transition.
• Initiate/facilitate post‑acute referrals through departmental processes for timely transition to the next level of care.
• Refer appropriate cases for social work intervention as per protocol.
• Accommodate cultural or religious beliefs in providing service and continuity of care.
• Collaborate with physicians and care team to facilitate communication regarding patients’ care progression.
• Proactively identify delays or obstacles in diagnostics or treatments, and discuss medical necessity for inpatient testing with physicians.
• Work to resolve barriers to discharge and engage appropriate leaders for efficient resolution.
• Complete initial clinical/psychosocial assessment and document it in the medical record.
• Ensure all records are up-to-date, documentation is clear and concise, and documentation is timely and accurate in progress notes.
• Track avoidable days and report trends that lead to undesirable outcomes.
• Complete all initial and ongoing professional competency assessments, mandatory education, and population-specific education.
• Support department-based goals contributing to organizational success.
• Serve as a preceptor and/or mentor for student interns (if appropriate).
• Perform other duties as assigned and comply with all Wellstar Health System policies, standards of work, and code of conduct.

• Associates Nursing or Diploma (Nurse) Nursing
• Bachelors Nursing (Preferred)

• RN – Registered Nurse (Single State) or RN‑COMPACT – RN – Multi‑state Compact
• BLS – Basic Life Support or ARC‑BLS – American Red Cross Basic Life Support or BLS‑I – Basic Life Support – Instructor

Minimum 1 year nursing experience in the acute care setting.

• Excellent written and verbal communication skills.
• Mature, self‑confidence, objectivity, and positive attitude.
• Self‑directed and able to function well under stress, handle change, and work in a fast‑paced environment.
• Strong assessment, interview, organizational, and problem‑solving skills.
• Knowledge of local, state, and federal regulations.
• Knowledge of community and statewide resources and programs.
• Ability to work collaboratively with physicians, care team members, and patients/family to facilitate progression of care during transition to the next level of care.