Care Coordinator - Registered Nurse (RN)

Wellstar Health System•LaGrange, GA

About The Position

The Care Coordinator RN (CC RN) assesses patients’ transitional care needs, coordinates care across the continuum, and engages patients and families to ensure their needs are met. The role plans effectively to meet patient needs, manage length of stay, and promote efficient use of resources. It integrates care facilitation, care progression, and transitional care planning. The coordinator assesses psychosocial and functional status, plans transitions, supports clinical care progression, facilitates patient and family care conferences, participates in interdisciplinary rounds, and provides education. The role collaborates 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 coordinator monitors progress toward discharge, helps address barriers, and consults appropriate disciplines and departments to resolve delays and facilitate discharge. Responsibilities include assessing chronic disease management needs, psychosocial risk factors, available resources, and insurance coverage requirements; developing and managing individualized discharge plans; arranging post-acute referrals; and coordinating timely transitions to the next level of care. The coordinator identifies care delays and discharge obstacles, works with physicians and care teams to resolve them, and documents assessments, interactions, services, and avoidable days in the medical record. The role also includes required education and competency assessments, supporting departmental goals, and serving as a preceptor or mentor for student interns when appropriate. Other duties may be assigned, and the employee must comply with Wellstar policies, standards of work, and code of conduct.

Requirements

Associate degree in Nursing or a nursing diploma; a Bachelor of Science in Nursing is preferred.
Current Registered Nurse license: single-state RN or RN compact multi-state license.
Current BLS certification, or an accepted American Red Cross BLS or BLS Instructor certification.
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.
Self-direction and the ability to function under stress, handle change, and work 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, patients, and families to support care progression and transition to the next level of care.

Nice To Haves

Bachelor of Science in Nursing.
Ability to serve as a preceptor or mentor for student interns, when appropriate.

Responsibilities

Assess patients’ transitional care needs, chronic disease management needs, psychosocial risk factors, functional status, and available discharge resources.
Coordinate care across the continuum and engage patients and families to ensure care needs are met.
Collaborate with physicians, utilization review nurses, financial counselors, the interdisciplinary care team, patients, and families on care progression, insurance requirements, and discharge planning.
Manage all aspects of discharge planning for assigned patients and develop individualized plans with patients, families, and physicians.
Identify and document barriers to timely disposition and work to resolve or escalate barriers to discharge.
Participate in interdisciplinary rounds and care conferences to confirm estimated discharge dates and recommend an appropriate level of care transition.
Initiate and facilitate post-acute referrals through departmental processes.
Refer appropriate cases for social work intervention according to departmental protocol.
Identify delays or obstacles in diagnostic testing or treatment and discuss the medical necessity of inpatient testing with physicians when outpatient testing may be more appropriate.
Document assessments, interactions, discharge plans, arranged services, and avoidable days accurately and promptly in the medical record.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Support department-based goals and serve as a preceptor or mentor for student interns when appropriate.
Perform other assigned duties and comply with Wellstar policies, standards of work, and code of conduct.