RN - Patient Care Coordinator

Fort HealthCare•Fort Atkinson, WI

3d•Onsite

About The Position

Fort HealthCare is seeking an RN Patient Care Coordinator to join their Comprehensive Care Team. The primary responsibility for this position is to coordinate and manage the safe and efficient discharge of patients from the hospital to their next level of care. This position is responsible for assessing, coordinating, and facilitating discharge plans that align with patient's medical needs, treatment goals, and patient preferences. Working collaboratively with physicians, nursing staff, interdisciplinary team members, patients, family, and community resources, the discharge planner develops and implements post-acute care plans. This position requires a balance of clinical knowledge, coordination skills, and compassionate communication. Fort HealthCare is proud to be named a 16-time award winner of the Top Workplace award for Southeastern Wisconsin, a 6-time award winner of the USA Top Workplaces award, and a 2-time winner of their Top Workplaces Culture Excellence award for Purpose & Values. In addition, Fort HealthCare has been recognized nationally as a Top Workplace for Nursing 2026. Our Mission Statement is our daily guide to provide the best health care possible. Our Vision Statement provides each of us at Fort HealthCare with a goal. The RN-Patient Care Coordinator ensures an effective discharge process that focuses on the patient's goals and treatment preferences and facilitates collaboration between the healthcare team and the patient and their caregivers/support person(s) as active partners in the discharge planning process.

Requirements

ADN required
Two years of nursing experience required
Exceptional understanding of the Nursing Process with emphasis on developing and maintaining care plans.
Exceptional communication and organizational skills.
Ability to work well with all disciplines and levels.
Acts as an agent for change.
Ability to collect, interpret and act on data.
Current WI RN License; BLS Certificate

Nice To Haves

BSN preferred

Responsibilities

Utilizes the nursing process to coordinate care of patients meeting case management criteria through collaboration with team members within and outside the organization.
Actively engages the patient and their caregiver(s) to assess self-care capabilities and incorporate the patient's goals and preferences as much as possible within the evaluation while also determining the patient's need for post-hospital services such as hospice care, post-hospital extended care, home health, non-health care services, or the need for community-based care providers.
Responsible and accountable for coordinating the care of patients across the continuum of care, ensuring and facilitating the achievement of quality, clinical and cost outcomes, negotiating, procuring, and coordinating services and resources needed by the patient and their caregiver/support person(s).
Participates in daily multidisciplinary rounds to collaborate with all disciplines and identify discharge needs, barriers to desired patient outcomes, and referral needs for the patient.
Facilitates communication between members of the healthcare team, the patient, caregiver/support person(s), and external facilities and community partners.
Assists other departments with care coordination and discharge planning as needed.
Performs admission, concurrent and discharge reviews for adherence to MCG criteria to ensure appropriate utilization of services.