Care Coordination RN

About the role

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.

Responsibilities

• Assess transitional care needs, coordinate care across the continuum, and engage with patient and family to assure care needs are met.
• Plan effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources.
• Integrate and coordinate care facilitation, care progression and transitional care planning functions.
• Perform psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education.
• Collaborate 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.
• Assure that the patient is progressing towards their discharge goal and assist to alleviate barriers.
• Seek consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.

Core Responsibilities And Essential Functions

Assessment

• Initiate assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge based on preliminary screening of patients.
• Partner with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.
• Collaborate 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.
• Meet with physicians and care team routinely to collaborate on timely and efficient patient management.

Disposition Planning

• Manage all aspects of discharge planning for assigned patients.
• Implement discharge planning timely and provide resources in an efficient manner.
• Meet with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.
• Identify and document barriers for timely disposition.
• Ensure/maintain discharge plan consensus with patient/family, physicians, care teams and payers.
• Respond to referrals for patients post-acute needs from physicians and the care team.
• Participate 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.
• Initiate/facilitate 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.
• Allow for any cultural or religious beliefs in providing service and continuity of care.

Care Progression

• Collaborate with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.
• Proactively identify delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.
• Identify and discuss with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.
• Actively work to resolve barriers to discharge and engage/escalate barriers to discharge to the appropriate leader for efficient resolution.

Documentation

• Complete initial clinical/psychosocial assessment and document 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.
• Account for and indicate all services arranged/delivered in electronic medical record.
• Track avoidable days and report trends that lead to undesired outcomes.

Professional Development and Initiative

• Complete all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Support department-based goals which contribute to the success of the organization.
• Serve as a preceptor and/or mentor for student interns (if appropriate).
• Perform other duties as assigned.
• Comply with all Wellstar Health System policies, standards of work, and code of conduct.

Requirements

• Associate's Degree in Nursing from an accredited school of nursing.
• Georgia RN License Required.
• All certifications are required upon hire unless otherwise stated.
• Basic Life Support or BLS - Instructor.
• Minimum 1 year nursing experience in the acute care setting.

Qualifications

• Excellent written and verbal communication skill.
• 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.