Care Coordinator RN - Family Medicine Clinic - Augusta, GA

Job Summary

The Care Coordinator RN (CC RN) at Wellstar is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patients and families to ensure care needs are met. 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
• Patient/family education

Core Responsibilities And Essential Functions

• Psychosocial and functional status assessment
• Transitional care planning
• Collaborates with the PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements for all payers
• 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
• 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
• Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers

Disposition Planning

• Manages all aspects of discharge planning for assigned patients
• Implements discharge planning timely and provides resources in an efficient manner
• Makes sure to meet 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

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
• 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 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
• Serves as a preceptor and/or mentor for student interns (if appropriate)
• Performs other duties as assigned

Required Minimum Education

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

Required Minimum License(s) And Certification(s)

• 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

Required Minimum Experience

Minimum 1 year nursing experience in the acute care setting

Required Minimum Skills

• Excellent written and verbal communication skill
• 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