RN Care Coordinator - WMCG

Wellstar Health System

2d•Onsite

About The Position

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Requirements

Minimum 1 year nursing experience in the acute care setting.
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 with progression of care through their transition to the next level of care.
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor

Nice To Haves

Bachelors Nursing

Responsibilities

Assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met.
Planning effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources.
Integrating and coordinating care facilitation, care progression and transitional care planning functions.
Performing Psychosocial and functional status assessment.
Transitional care planning.
Clinical care progression.
Facilitating patient/family care conferences.
Participating in interdisciplinary rounds.
Patient/family education.
Collaborating 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.
Assuring that the patient is progressing towards their discharge goal and assisting to alleviate barriers.
Seeking consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.
Initiating assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.
Partnering with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
Collaborating 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.
Meeting with physicians and care team routinely to collaborate on timely and efficient patient management.
Managing all aspects of discharge planning for assigned patients.
Implementing discharge planning timely and providing resources in an efficient manner.
Meeting with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
Identifying and documenting barriers for timely disposition.
Ensuring/maintaining discharge plan consensus with patient/family, physicians, care teams and payers.
Responding to referrals for patients post-acute needs from physicians and the care team.
Participating 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.
Initiating/facilitating post-acute referrals through departmental processes for timely transition to the next level of care.
Referring appropriate cases for social work intervention based on departmental protocol.
Allowing for any cultural or religious beliefs in providing service and continuity of care.
Collaborating with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.
Proactively identifying delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.
Identifying and discussing with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.
Actively working to resolve barriers to discharge and engaging/escalating barriers to discharge to the appropriate leader for efficient resolution.
Completing and documenting initial clinical/psychosocial assessment in the medical record.
Ensuring all records are up-to-date and documentation is clear and concise.
Ensuring 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.
Accounting for and indicating all services arranged/delivered in electronic medical record.
Tracking avoidable days and reporting trends that lead to undesired outcomes.
Completing all initial and ongoing professional competency assessment, required mandatory education, population specific education.
Supporting department-based goals which contribute to the success of the organization.
Serving as a preceptor and/or mentor for student interns (if appropriate).
Performing other duties as assigned.
Complying with all Wellstar Health System policies, standards of work, and code of conduct.