Registered Nurse (RN)-Acute Care- Care Coordination Sr. (ED 12 Hour Daytime)

Wellstar Health System•Phenix City, AL

6d•Onsite

About The Position

Wellstar is seeking a Registered Nurse (RN) Senior for Acute Care Care Coordination to join their Cobb Hospital team. This role focuses on assessing transitional care needs, coordinating care across the continuum, and engaging with patients and families to ensure their care needs are met, particularly in complex cases during acute admissions. The RN Senior will utilize strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans, streamline progression of care, and plan for post-discharge needs. This position serves as an expert resource and consultant to other team members regarding care progression and planning to effectively meet patient needs, manage length of stay, and promote efficient resource utilization. The role integrates and coordinates care facilitation, care progression, and transitional care planning functions.

Requirements

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination.
Minimum 2 years in care coordination in the acute care setting required.
Minimum 3 years experience as a staff nurse in an acute care hospital setting.
Minimum 2 years experience as a case manager in a hospital setting or payer-based model with expertise in case management competencies and to guide the care team through complex discussions.
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 through the continuum of care.
BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

Nice To Haves

Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

Responsibilities

Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family education.
Collaborates effectively 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, any social determinants of health needs, goals/outcome attainment and continued care needs.
Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers.
Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.
Participates in orientation and precepting of new employee hires (as needed). The RN Sr will mentor new hires in clinical progression/case reviews and efficient transitional/discharge planning.
Initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.
Partners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.
Meets with physicians and care team routinely to collaborate on timely and efficient patient management.
Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.
Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.
Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.
Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution.
Manages all aspects of discharge planning for assigned patients.
Implements discharge planning timely and provides resources in an efficient manner.
Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
Identifies and documents barriers for timely disposition.
Responds to referrals for patients post-acute needs from physicians and the care team.
Participates 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.
Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.
Initiates/facilitates 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.
Allows for any cultural or religious beliefs in providing service and continuity of care.
Initial clinical/psychosocial assessment completed and documented 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.
Accounts for and indicates all services arranged/delivered in electronic medical record.
Track avoidable days and report trends that lead to undesired outcomes.
Assist leadership with precepting new hires when needed.
Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.
Serves as a preceptor and/or mentor for student interns.
Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
Supports department-based goals which contribute to the success of the organization.
Performs other duties as assigned.
Complies with all Wellstar Health System policies, standards of work, and code of conduct.