Care Coordination RN

The Care Coordinator RN at Wellstar is responsible for assessing and coordinating patient care transitions, including psychosocial and functional status assessments, care planning, and facilitating patient and family education. The role involves collaboration with physicians, interdisciplinary teams, and care teams to ensure efficient discharge planning and timely care progression. Key duties include managing discharge plans, identifying and resolving barriers to care, and maintaining accurate documentation. Candidates must have an Associate’s or Diploma in Nursing (Nurse) or a Bachelor’s in Nursing (Nurse), a valid RN license (Single State or Multi-state Compact), and BLS certification. At least one year of acute care nursing experience is required. Strong communication, assessment, and organisational skills are essential, along with knowledge of relevant regulations and community resources. The Care Coordinator RN (CC RN) at Wellstar plays a vital role in supporting the health and well-being of patients by coordinating care across the continuum. This position is responsible for assessing transitional care needs, facilitating care planning, and engaging with patients and families to ensure comprehensive care needs are met. The CC RN collaborates with interdisciplinary teams to assess medical, psychosocial, and social determinants of health, manages discharge planning, and ensures efficient resource utilisation. The role requires strong communication, assessment, and documentation skills, as well as a commitment to professional development. This is a day shift position within a mission-driven healthcare environment focused on excellence and compassionate service.

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.

Work Shift

Day (United States of America)

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. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions. Specific functions within this role include: Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education Collaborates 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 Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. May have other duties assigned

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 patients 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 patients 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 patients 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. * Identities 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 patients 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.

Required Minimum Education:

• Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• 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

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 1 year nursing experience in the acute care setting. Required

Required Minimum Skills:

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.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

• 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 s Responsibilities
• Responsible for assessing transitional care needs and coordinating care across the continuum.
• Play a key role in shaping patient and family education and care conferences.
• Collaborate cross-functionally to assess insurance and coverage requirements for all payers.
• Take ownership of discharge planning, including managing all aspects of discharge and developing individualised discharge plans.
• Deliver high-quality documentation in medical records and progress notes.
• Lead efforts to identify and document barriers to timely discharge and escalate issues as needed.
• Help drive innovation in care progression by proactively identifying and resolving delays in care.
• Collaborate with physicians and care teams to facilitate communication regarding patient care progression.
• Support department-based goals and serve as a preceptor or mentor for student interns if appropriate. Skills
• Excellent written and verbal communication skills are essential.
• Strong assessment, interview, organisational, and problem-solving skills are required.
• Maturity, self-confidence, objectivity, and a positive attitude are necessary.
• Ability to function well under stress, handle change, and work in a fast-paced environment is important.
• Knowledge of local, state, and federal regulations is required.
• Familiarity with community and state-wide resources and programmes is necessary.
• Ability to collaborate effectively with physicians, care teams, and patients/families is required.
• A minimum of 1 year of nursing experience in the acute care setting is required. Education
• An Associate's degree in Nursing or Diploma (Nurse) is required.
• A Bachelor's degree in Nursing is preferred.
• All certifications are required upon hire, including 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 are required.