Care Coordinator RN

CommonSpirit Health • Sacramento, CA

17h • Onsite

About The Position

The RN Care Coordinator helps patients and 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 care plans, advocate for patients, facilitate transitions, monitor progress toward goals, and connect patients with appropriate community and healthcare resources.

The Care Coordinator completes and documents discharge-planning assessments for patients identified through the designated screening process or by request, reassessing patients as appropriate and updating plans. The role develops multidisciplinary discharge plans with relevant healthcare team members, patients or their representatives, and post-acute care providers, considering clinical and psychosocial needs, patient choices, and available resources. It also supports timely transitions to appropriate post-acute services, identifies readmission risks, implements interventions to mitigate those risks for at least 30 days, and provides patient education and advocacy.

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, required 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 the managed-care and 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 by request; reassess patients and update plans as appropriate.
• Facilitate multidisciplinary discharge planning with relevant healthcare team members, the patient or patient representative, and post-acute care providers, based on clinical and psychosocial needs, choices, and available resources.
• Collaborate with the healthcare team and post-acute service providers to support timely, smooth transitions to appropriate post-acute services.
• Identify readmission risks and implement interventions to mitigate them for at least 30 days.
• Provide patient education and advocacy.
• Assess patient needs, coordinate services, develop individualized 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