Aortic Surveillance Patient Care Coordinator

Vanderbilt University Medical Center • Nashville, TN

1d

About The Position

The Aortic Surveillance Patient Care Coordinator supports nursing care coordination for a defined patient population or disease process. The role contributes to financial, satisfaction, and clinical outcomes and improves patient outcomes by helping reduce all-cause hospital readmissions and coordinating care episodes. It supports patient and family engagement in self-care, timely handovers to the next level of care, education using the teach-back method, follow-up phone calls, and navigation of the healthcare system.

The coordinator works with referring providers, Vanderbilt providers, clinical teams, and other care partners to coordinate care from anchor hospitalization through the defined care episode. The role supports evaluation, pre-admission and post-discharge transitions, discharge planning, patient education, and handovers to outpatient care coordinators, home health nurses, cardiac rehabilitation, and skilled nursing facilities. It also evaluates coordination practices and supports evidence-based protocols.

This position requires registered nurse licensure, a bachelor's-level education, and five years of relevant work experience. The role is part of Vanderbilt Health's Nashville clinical staff organization.

Requirements

• Registered Nurse licensure.
• Bachelor's degree.
• Five years of relevant work experience.
• Advanced capability in evidence-based practice, including implementing and evaluating practice changes based on published research.
• Advanced patient education capability across the care continuum, including treatment planning in complex situations.
• Advanced nursing patient assessment and evaluation capability; the technical capabilities description includes conducting primary care interviews and physical examinations.
• Intermediate trend analysis capability, including recognizing patterns and accounting for seasonality and randomness.

Responsibilities

• Coordinate the evaluation process for the defined patient population and collaborate with team members to complete required information.
• Support patient access by serving as a liaison between referring providers' offices and Vanderbilt providers.
• Work with the clinical team to develop a collaborative plan coordinating patient care from anchor hospitalization through the defined care episode.
• Develop and manage processes for pre-admission and post-discharge care transitions.
• Establish relationships and clinical pathways with providers and agencies to optimize care for the defined patient population.
• Assist in developing and disseminating patient education materials, including customized medication grids with input from the pharmacist or team as needed.
• Assist with discharge and transition planning in collaboration with the multidisciplinary team, engaging outpatient care providers and sharing relevant information about the hospital course, 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.
• Educate patients and families on key elements of personal care plans using the teach-back method and conduct follow-up phone calls.
• Encourage patient and family engagement in self-care management and help patients navigate the healthcare system.
• Evaluate care coordination practices and support development of evidence-based practice protocols.
• Contribute to key Pillar outcomes and system improvement goals, including financial, satisfaction, and clinical outcomes.

Benefits

• Affordable high-quality health plan options.
• Dental and/or vision plan.
• 403(b) retirement plan.
• Paid time off (flex PTO).
• Tuition reimbursement.
• Adoption assistance, subject to maximums.
• Short- and long-term disability.
• Subsidized backup childcare.
• Inpatient nursing supplemental pay program may be available; ask about current program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level