Care Coordinator RN Kennestone Hospital

3110 Kennestone Hospital, Inc.•Marietta, GA

11d

About The Position

The Care Coordinator RN assesses patients’ transitional care needs, coordinates care across the continuum, and engages patients and families to ensure care needs are met. The role plans for patient needs, manages length of stay, and promotes efficient use of resources by integrating care facilitation, care progression, and transitional care planning. Responsibilities include assessing psychosocial and functional status, coordinating transitional care planning and clinical care progression, facilitating patient and family care conferences, participating in interdisciplinary rounds, and providing education. The Care Coordinator RN works with utilization review nurses, physicians, and the interdisciplinary care team to assess medical and psychosocial needs, social determinants of health, goals and outcomes, and ongoing care needs. The role monitors progress toward discharge goals, identifies and helps resolve barriers and delays, and coordinates an appropriate transition to the next level of care.

Requirements

Associate degree or diploma in nursing; a Bachelor of Science in Nursing is preferred.
Current RN license (single-state or multistate compact).
BLS certification or an accepted American Red Cross or instructor equivalent.
At least 1 year of nursing experience in an acute care setting.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, manage stress and change, and function in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of applicable local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, and patients and families to support care progression and transitions.

Nice To Haves

Bachelor of Science in Nursing.

Responsibilities

Assess patients’ chronic disease management needs, psychosocial risk factors, and available discharge resources.
Partner with the PAS, financial counselor, and/or utilization management nurse to assess insurance and coverage requirements.
Collaborate with patients, families, physicians, and care team members to establish and support care progression and discharge plans.
Manage discharge planning for assigned patients, including assessing needs, developing individualized plans, providing resources, and arranging post-acute referrals.
Identify and document barriers to timely disposition and maintain discharge-plan consensus among patients, families, physicians, care teams, and payers.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend the appropriate level of care transition.
Refer appropriate cases for social work intervention and account for cultural or religious beliefs in service and continuity of care.
Identify delays or obstacles in diagnostic testing or treatment, discuss inpatient testing needs with physicians, and work to resolve or escalate discharge barriers.
Complete and maintain clear, timely, and accurate clinical and psychosocial assessments and documentation in the medical record.
Document interactions and services arranged or delivered, track avoidable days, and report trends associated with undesired outcomes.
Complete required competency assessments and mandatory and population-specific education.
Support department goals, serve as a preceptor or mentor for student interns when appropriate, and comply with Wellstar policies, standards of work, and code of conduct.
Perform other duties as assigned.