AHD RN Care Coordinator

Summary

The AHD RN Care Coordinator is responsible for coordinating the continuum of care and discharge planning activities for a caseload of assigned patients. They complete initial assessments and develop discharge plans, monitor clinical activities, make recommendations for alternative levels of care, and identify cost-effective protocols. They follow regulatory compliance guidelines and serve as an active member of the multidisciplinary team.

Duties & Essential Job Functions

• Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.
• Confirms all applicable department and regulatory targets for department performance process improvements are attained (e.g., readmissions, throughput, LOS).
• Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social work, and other healthcare providers and agencies. Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record. Processes referrals and authorizations that adhere to federal, state and local insurance regulatory agencies and offer patient choice per regulation.
• Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources. In coordination with patient and family wishes, guide/assist in securing needed post discharge services.
• Identifies potential problems, prevents, and/or resolves barriers to the discharge plan. Along with the social work team member, makes independent assessments and recommendations regarding course of action in complex situations.
• Mobilize resources to effect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.
• Ensures continuity of care through effective communication in rounds and written documentation in the EHR, transfer coordination, and discharge planning.
• Collaborates with the UR Specialist and communicates to the attending physician, when cases do not meet level of care criteria, in addition to documenting treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards.
• Reassesses the patient’s condition when changes occur and revises the care plan when appropriate to ensure effective resource utilization and appropriate level of care.
• Identifies and documents barriers (Avoidable Days) in the EHR.

Minimum Qualifications

• Required Education: Bachelor in Nursing
• Required Experience: Three years of acute care nursing

Additional Information

• A Community Hospital in Alameda County … and so much more For generations, Alameda residents have found friendly, familiar faces and dedicated medical attention at their local hospital. Now, more and more individuals in Oakland and throughout the East Bay are turning to Alameda Hospital for quality care. We welcome all patients seeking an Alameda County Hospital or Bay Area Hospital who value a state-of-the-art medical facility, with a human touch. Alameda Hospital. We care.