Registered Nurse (RN) Care Coordinator - FT/Day - Augusta

Wellstar Health System

About The Position

The Care Coordinator RN assesses patients’ transitional care needs, coordinates care across the continuum, and engages patients and families to ensure care needs are met. The role plans for patient needs, manages length of stay, and promotes efficient use of resources by integrating care facilitation, care progression, and transitional care planning. Responsibilities include psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitating patient/family care conferences, participating in interdisciplinary rounds, and providing patient/family education. The Care Coordinator RN 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 continuing care needs. The RN monitors progress toward discharge goals, helps resolve barriers and delays, and seeks input from appropriate disciplines or departments to facilitate timely care and discharge. The role includes assessing chronic disease management needs, psychosocial risks, and post-discharge resources; coordinating discharge planning and post-acute referrals; collaborating on care progression; and maintaining clear, timely documentation. The RN also completes professional competency and required education, supports departmental goals, may serve as a preceptor or mentor for student interns when appropriate, and complies with Wellstar policies and standards.

Requirements

Associate degree in Nursing or nursing diploma required; Bachelor’s degree in Nursing preferred.
Current RN license: single-state RN or multi-state compact RN.
BLS certification required; accepted options include Basic Life Support, American Red Cross Basic Life Support, or Basic Life Support Instructor.
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-directed, with the ability to function under stress, adapt to 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’s degree in Nursing.
Ability to serve as a preceptor and/or mentor for student interns, when appropriate.

Responsibilities

Assess patients’ chronic disease management needs, psychosocial risk factors, and available 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 on care progression and discharge plans.
Meet routinely with physicians and the care team to support timely and efficient patient management.
Manage discharge planning for assigned patients and implement plans in a timely, resource-efficient manner.
Assess patient and family needs and develop individualized discharge plans in collaboration with physicians.
Identify and document barriers to timely disposition and maintain agreement on discharge plans among patients, families, physicians, care teams, and payers.
Respond to referrals for patients’ post-acute needs and initiate or facilitate post-acute referrals through departmental processes.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend the appropriate level of care transition.
Refer appropriate cases for social work intervention according to departmental protocol.
Respect cultural and religious beliefs when providing services and continuity of care.
Identify delays or obstacles in diagnostic testing or treatment and work with physicians and the care team to resolve them.
Discuss with physicians whether inpatient testing may be more appropriate in an outpatient setting.
Escalate discharge barriers to the appropriate leader when needed.
Complete and document initial clinical and psychosocial assessments in the medical record.
Maintain up-to-date records and clear, concise, timely documentation of interactions and services arranged or delivered.
Track avoidable days and report trends that lead to undesired outcomes.
Complete initial and ongoing competency assessments, mandatory education, and population-specific education.
Support department-based goals and serve as a preceptor and/or mentor for student interns when appropriate.
Perform other assigned duties and comply with Wellstar policies, standards of work, and code of conduct.