Care Coordinator RN (Weekdays M-F) @Cobb hospital

2510 Cobb Hospital, Inc.•Mableton, GA

6d•Onsite

About The Position

Wellstar is seeking a dedicated Care Coordinator RN to join their Cobb Hospital Care Coordination team. This role is crucial in assessing transitional care needs, coordinating patient care across the continuum, and ensuring patient and family needs are met. The Care Coordinator RN plays a key part in effective patient planning, managing length of stay, and promoting efficient resource utilization. The position integrates and coordinates care facilitation, care progression, and transitional care planning functions.

Requirements

Minimum 1 year nursing experience in the acute care setting.
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
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 assist with progression of care through their transition to the next level of care.

Nice To Haves

Bachelors Nursing

Responsibilities

Psychosocial and functional status assessment
Transitional care planning
Clinical care progression
Facilitate patient/family care conferences
Participate in interdisciplinary rounds
Patient/family education
Collaborate with the utilization review nurse, patient's physicians, and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, social determinants of health needs, goals/outcome attainment, and continued care needs.
Assure that the patient is progressing towards their discharge goal and assist to alleviate barriers.
Seek consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.
Manage all aspects of discharge planning for assigned patients.
Implement discharge planning timely and provide resources in an efficient manner.
Meet with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
Identify and document barriers for timely disposition.
Ensure/maintain discharge plan consensus with patient/family, physicians, care teams, and payers.
Respond to referrals for patients post-acute needs from physicians and the care team.
Participate 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.
Initiate/facilitate 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.
Allow for any cultural or religious beliefs in providing service and continuity of care.
Collaborate with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.
Proactively identify delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.
Identify and discuss with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.
Actively work to resolve barriers to discharge and engage/escalate barriers to discharge to the appropriate leader for efficient resolution.
Complete initial clinical/psychosocial assessment and document 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.
Account for and indicate all services arranged/delivered in electronic medical record.
Track avoidable days and report trends that lead to undesired outcomes.
Complete all initial and ongoing professional competency assessment, required mandatory education, population specific education.
Support department-based goals which contribute to the success of the organization.
Serve as a preceptor and/or mentor for student interns (if appropriate).
Perform other duties as assigned.
Comply with all Wellstar Health System policies, standards of work, and code of conduct.