Care Coordination RN

CommonSpirit Health • Stockton, CA

3d • Onsite

About The Position

The RN Care Coordinator helps patients and their families navigate the healthcare continuum and coordinates individualized care plans to support optimal health outcomes and seamless transitions across care settings. The role collaborates with interdisciplinary teams to assess patient needs, coordinate services, develop comprehensive care plans, advocate for patients, facilitate transitions of care, monitor progress toward goals, and connect patients with appropriate community and healthcare resources.

The position completes and documents discharge planning assessments for patients identified through the designated screening process or upon request, reassessing patients as appropriate and updating plans. It facilitates multidisciplinary discharge planning with relevant health team members, patients or their representatives, and post-acute care providers, taking into account clinical and psychosocial needs, patient choices, and available resources. The coordinator works with healthcare teams and post-acute providers to ensure timely transitions to appropriate services and identifies readmission risks, implementing interventions to mitigate them for at least 30 days. Patient education and advocacy are also key responsibilities.

Requirements

• Graduate of an accredited school of nursing.
• At least two years of acute hospital clinical experience, or a master's degree in Case Management or a Nursing field in lieu of one year of experience.
• Active Registered Nurse (RN) license in the State of California.
• Basic Life Support (BLS) certification from the American Heart Association within three months of hiring.
• Knowledge of CMS standards and requirements.
• Ability to apply clinical guidelines to ensure progression of care.
• Critical-thinking and problem-solving skills.
• Ability to collaborate effectively with multiple stakeholders and communicate professionally.
• Understanding of how utilization management and case management programs integrate.
• Ability to work as a team player and assist other team members as needed.
• Ability to thrive in a fast-paced, self-directed environment.
• Ability to prioritize work and delegate where indicated.
• Strong organization and time-management skills.

Nice To Haves

• Knowledge of managed care and the payer environment.
• Bachelor's degree in Nursing (BSN) or a related healthcare field.
• At least five years of nursing experience.
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM certification.

Responsibilities

• Complete and document discharge planning assessments for patients identified through the designated screening process or upon request; reassess patients as appropriate and update plans.
• Facilitate multidisciplinary discharge planning with relevant healthcare team members, patients or their representatives, and post-acute care providers, based on clinical and psychosocial needs, choices, and available resources.
• Collaborate with healthcare teams and post-acute service providers to coordinate timely transitions to appropriate post-acute services and settings.
• Identify readmission risks and implement interventions to mitigate those risks for at least 30 days.
• Provide patient education and advocacy.
• Assess patient needs, coordinate services, develop care plans, monitor progress toward goals, and connect patients with community and healthcare resources.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree