Registered Nurse (RN) Care Coordinator

Wellstar Health System•Griffin, GA

About The Position

The Care Coordinator 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 for patient needs, manages length of stay, promotes efficient resource utilization, and integrates care facilitation, care progression, and transitional care planning. Responsibilities include psychosocial and functional assessments, transitional care planning, clinical care progression, facilitating patient and family care conferences, participating in interdisciplinary rounds, and providing education to patients and families. The Care Coordinator RN collaborates with utilization review nurses, physicians, and interdisciplinary care teams to assess medical and psychosocial needs, social determinants of health, goals and outcomes, and ongoing care requirements. The RN monitors progress toward discharge goals, works to address barriers, and consults appropriate disciplines or departments to resolve delays and facilitate discharge. The role may include other assigned duties.

Requirements

Associate degree in Nursing or nursing diploma required; Bachelor of Science in Nursing preferred.
Current RN license: single-state RN or RN compact license.
Basic Life Support certification through BLS, 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.
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, patients, and families to support progression of care through transition to the next level of care.

Responsibilities

Assess chronic disease management needs, psychosocial risk factors, and available post-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.
Meet routinely with physicians and the care team to support timely, efficient patient management.
Manage discharge planning for assigned patients and implement plans in a timely, resource-efficient manner.
Meet with patients and families to assess needs and develop individualized discharge plans with physicians.
Identify and document barriers to timely disposition and maintain consensus on discharge plans among patients, families, physicians, care teams, and payers.
Respond to referrals for patients’ post-acute needs and participate in interdisciplinary rounds to confirm estimated discharge dates and recommend appropriate care transitions.
Initiate or facilitate post-acute referrals and refer appropriate cases for social work intervention according to departmental protocol.
Respect cultural and religious beliefs when providing services and continuity of care.
Coordinate communication with physicians and the care team about patient care progression.
Identify delays or obstacles in diagnostic testing or treatment that could delay discharge; discuss with physicians when inpatient testing may be more appropriate in an outpatient setting.
Work to resolve discharge barriers and escalate them to appropriate leaders when needed.
Complete and document initial clinical and psychosocial assessments in the medical record; maintain clear, concise, timely, and accurate documentation.
Record patient and family, physician, care team, and community partner interactions related to discharge planning, and document services arranged or delivered in the electronic medical record.
Track avoidable days and report trends that may lead to undesired outcomes.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Support department goals, 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.