Care Coordinator RN

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 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)

Ideal candidates will possess prior experience as a Care Coordinator in an Acute Care setting.

The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with the patient and family to assure care needs are met. The CC RN plans effectively to meet the patient’s needs, manages the length of stay and promotes efficient utilization of resources. 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 with the utilization review nurse, patient’s physicians and the interdisciplinary care team to provide a comprehensive assessment of medical, psychosocial, social determinants of health needs, goals/outcome attainment and continued care needs.
• Assures patient progress toward discharge goals and assists to alleviate barriers.
• Seeks consultation from appropriate disciplines/departments to proactively identify and resolve delays to expedite care and discharge.
• May have other duties assigned.

• Based on preliminary screening of patients, initiates assessment of 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.
• Collaborates with the patient and family, along with the physician(s) and other care team members to establish and support 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 discharge date and recommend best level of care transition.
• Initiates/facilitates post-acute referrals for timely transition to the next level of care.
• Refer appropriate cases for social work intervention per departmental protocol.
• Respect culturally or religiously informed needs in providing service and continuity of care.

• Collaborates with physicians and care team to facilitate communication regarding patient progression for timely care delivery.
• Proactively identifies delays/obstacles in diagnostic or treatment steps that can lead to discharge delays.
• Identifies medical necessity for inpatient testing that may be appropriate in the outpatient setting, and discusses with the physician.
• Resolves barriers to discharge and escalates as needed to appropriate leadership for resolution.

• Initial clinical/psychosocial assessment documented in the medical record.
• Ensures records are up-to-date and documentation is clear and concise.
• Documents interactions with patient/family, physicians, care team, and community partners related to discharge planning.
• Records services arranged/delivered in the…