Care Coordinator RN PRN

Job Summary

Care Coordinator RN primarily responsible for Discharge Planning for acute care patients  work is supplemental as needed but available to work 3 shifts a month with a flexible cadence based on unit needs.

PRN supplemental; available to work 3 shifts a month with a flexible cadence based on unit needs.

• Assessment
  • 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.
• Care Progression
  • 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.
• Disposition Planning
  • 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 at discharge.
  • Ensures/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.
• Documentation
  • 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.
• Precepting / Mentoring
  • Assist leadership with precepting new hires when needed.
  • Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
  • Serves as a preceptor and/or mentor for student interns.
• Professional Development and Initiative
  • Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
  • Supports department-based goals which contribute to the success of the organization.
  • Performs other duties as assigned.
  • Complies with all Wellstar Health System policies, standards of work, and code of conduct.

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

• BLS
  - Basic Life Support or ARC-BLS
  - Amer Red Cross Basic Life Support or BLS-I
  - Basic Life Support
  - Instructor
• RN
  - Reg Nurse (Single State) or RN-COMPACT - RN
  - Multi-state Compact

ACM or CCM Preferred

• Minimum 3 years experience as a staff nurse in an acute care hospital setting.
• Minimum 2 years experience as a case manager in a hospital setting or payer-based model with expertise in case management competencies and to guide the care team through complex discussions.

• Excellent written and verbal communication skill.
• Must possess maturity, self-confidence, objectivity, and positive attitude.
• Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment.
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge regarding local, state and federal regulations required.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, members of the care team, and the patient/family to…