Registered Nurse (RN) Care Coordinator

Job Summary

The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. The CC RN plans effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources. The role integrates and coordinates care facilitation, care progression and transitional care planning functions.

Core Responsibilities and Essential Functions

Assessment

• Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.
• Partners with the PAS, financial counselor 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 patient's care progression and discharge plans.
• Meets with physicians and care team routinely to collaborate on timely and efficient patient management.

Disposition Planning

• 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.
• Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.
• Responds to referrals for patients post-acute needs from physicians and the care team.
• Participates in Interdisciplinary Rounds with the patient's care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
• 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.

Care Progression

• Collaborates with physicians and care team to facilitate communication regarding patient's 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.
• Identifies 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.

Documentation

• 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 patient's 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.

Professional Development and Initiative

• 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.
• Serves as a preceptor and/or mentor for student interns (if appropriate).
• Performs other duties as assigned.
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.