Care Coordinator RN PRN

Work Shift

PRN is supplemental as needed but available to work 3 shifts a month with a flexible cadence based on unit needs.

Care Coordinator RN primarily Discharge Planning for Paulding acute care related patients. The Care Coordinator RN Sr. is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met on the most complex cases during the patient's acute admission.

The RN Sr requires strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans to streamline progression of care while in the hospital, as well as, planning for post discharge care. The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively 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.

• Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, 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
• Will participate in orientation and precepting of new employee hires (as needed). The RN Sr will mentor new hires in clinical progression/case reviews and efficient transitional/discharge planning
• May have other duties assigned

Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. Partners with the PAS, financial counselors, 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 patients care progression and discharge plans.

Meets with physicians and care team routinely to collaborate on timely and efficient patient management.

Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care. 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. Responds to referrals for patients post-acute needs from physicians and the care team. Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition ures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.

Initiates/facilitates 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. Allows for any cultural or religious beliefs in providing service and continuity of care.

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

Assist leadership with precepting new hires when needed. Mentoring new and less…