Aortic Surveillance Patient Care Coordinator

Vanderbilt University Medical Center•Nashville, TN

About The Position

The Aortic Surveillance Patient Care Coordinator supports nursing care coordination for a defined patient population or disease process. The role helps achieve clinical, satisfaction, and financial outcomes by coordinating episodes of care, reducing avoidable hospital readmissions, supporting patient and family engagement in self-care, and helping patients navigate the healthcare system. The coordinator promotes timely, standardized handovers between care settings and provides patient and family education using the teach-back method and follow-up phone calls. The position coordinates patient evaluation and access, collaborates with clinical teams on care plans, and manages pre-admission and post-discharge transitions. It contributes to patient education materials and transition planning, and shares relevant hospital-course information with outpatient providers and other care partners. The role also evaluates care coordination practices and supports evidence-based protocols. Additional duties may be assigned.

Requirements

Registered Nurse licensure is required.
Bachelor's degree.
Five years of experience; the posting lists the experience level as 5 years.
Advanced capability in evidence-based practice, including implementing and evaluating practice changes based on published research.
Advanced capability in RN access patient education and treatment planning across the care continuum.
Advanced capability in nursing patient assessment and evaluation, including patient interviews and physical examinations.
Intermediate trend analysis capability.

Responsibilities

Coordinate the evaluation process for the defined patient population and document portions of the evaluation when appropriate, collaborating with team members to ensure required information is complete.
Support patient access by serving as a liaison between referring provider offices and Vanderbilt providers.
Collaborate routinely with the clinical team to develop a care coordination plan spanning the anchor hospitalization and defined care episode.
Develop and manage pre-admission and post-discharge care transition processes, and establish relationships or clinical pathways with providers and agencies to optimize care.
Assist in developing and disseminating patient education materials, including customized medication grids with pharmacist or team input as needed.
Assist with discharge and transition planning alongside the multidisciplinary team, engaging outpatient care providers and sharing relevant hospital-course information, concerns, pending test results, learning needs, and partnership opportunities.
Coordinate handovers with outpatient care coordinators, home health nurses, cardiac rehabilitation, skilled nursing facilities, and other care partners.
Evaluate care coordination practices and support the development of evidence-based practice protocols.
Help identify appropriate patients, encourage patient and family engagement in self-care management, provide standardized handovers, conduct education using teach-back, make follow-up phone calls, and help patients navigate the healthcare system.