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Work Shift

Various (United States of America)

Job Summary:\rThe Care Coordinator RN Sr. (RN Sr) 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 most complex cases during the patient's acute admission. The RN Sr requires strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans to streamline progression of care while in the hospital, as well as, planning for post discharge care. The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.\rSpecific functions within this role include:\rTransitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family education\rCollaborates 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\rAssures that the patient is progressing towards their discharge goal and assists to alleviate barriers\rSeeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.\rWill participate 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.\rMay have other duties assigned.\rCore Responsibilities and Essential Functions:\r__Assessment__\rBased on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.\rPartners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.\rCollaborates 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.\rMeets with physicians and care team routinely to collaborate on timely and efficient patient management.\r__Care Progression__\rCollaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.\rProactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.\rIdentities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.\rActively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution\r__Disposition Planning__\rManages all aspects of discharge planning for assigned patients.\rImplements discharge planning timely and provides resources in an efficient manner.\rMeets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.\rIdentifies and documents barriers for timely disposition.\rResponds to referrals for patients post-acute needs from physicians and the care team.\rParticipates 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.\rEnsures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.\rInitiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.\rRefer appropriate cases for social work intervention based on departmental protocol.\rAllows for any cultural or religious beliefs in providing service and continuity of care.\r__Documentation__\rInitial clinical/psychosocial assessment completed and documented in medical record.\rEnsure all records are up-to-date and documentation is clear and concise.\rEnsure 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.\rAccounts for and indicates all services arranged/delivered in electronic medical record.\rTrack avoidable days and report trends that lead to undesired outcomes.\r__Precepting/Mentoring__\rAssist leadership with precepting new hires when needed.\rMentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.\rServes as a preceptor and/or mentor for student interns\r__Professional Development and Initiative__\rCompletes all initial and ongoing professional competency assessment, required mandatory education, population specific education.\rSupports department-based goals which contribute to the success of the organization.\rPerforms other duties as assigned\rComplies with all Wellstar Health System policies, standards of work, and code of conduct.\rRequired Minimum Education:Bachelors Nursing\r\rRequired Minimum License(s) and Certification(s):\rAll certifications are required upon hire unless otherwise stated.Reg Nurse (Single State) or RN - Multi-state CompactBasic Life Support or BLS - InstructorCertified Case Manager-Preferred or Accredited Case Manager-Preferred\rAdditional License(s) and Certification(s):\rACM or CCM Preferred\rRequired Minimum Experience:\rMinimum 3 years experience as a staff nurse in an acute care hospital setting. Required and\rMinimum 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. Required\rRequired Minimum Skills:\rExcellent written and verbal communication skill.\rMust possess maturity, self-confidence, objectivity, and positive attitude.\rSelf-directed with the ability to function well under stress, handle change, and function in a fast-paced environment\rStrong assessment, interview, organizational and problem-solving skills.\rKnowledge regarding local, state and federal regulations required.\rKnowledge of community and state-wide resources and programs.\rAbility to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

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