Registered Nurse - Complex Case Care Coordinator

About the role

The RN Complex Care Coordinator assesses and manages the needs of complex patients, ensuring safe and timely discharge planning while coordinating care across multiple settings.

Responsibilities

• Conduct comprehensive clinical and psychosocial assessments for high-risk patients, identifying barriers to discharge and resource needs.
• Develop and implement individualized discharge plans in collaboration with the care team, patients, and families.
• Facilitate referrals to community services, post-acute care, and social support resources, advocating for patient-centered decision-making.
• Serve as an expert resource on complex social determinants, end-of-life planning, and psychosocial issues, guiding the interdisciplinary team.
• Participate in team meetings, coordinate with community agencies, and support efforts to reduce hospital stay length and resource utilization.
• Mentor and precept new staff and interns, sharing expertise on complex care scenarios and family dynamics.
• Ensure accurate documentation of assessments, interventions, and services in electronic health records.

Qualifications

• Strong clinical and social expertise
• Knowledge of community resources, discharge planning, and social determinants of health

Skills

• Excellent communication and collaboration skills
• Ability to mentor others
• Ability to handle complex psychosocial situations