Registered Nurse (RN) -Acute Care - Care Coordination- FT Days

Come join our Cobb Hospital Care Coordination team at Wellstar, where your contributions and ideas are valued, and you can serve with compassion, pursue excellence, and honor every voice. Our mission is to enhance the health and well-being of every person we serve.

About the Role

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patients and families to ensure care needs are met. This role serves as an expert resource for complex patient situations and consults with care team members regarding clinical, psychosocial, and resource needs. The Complex Care Coordinator, in conjunction with the patient and physician, assesses, coordinates, and implements a timely, safe discharge plan to the next appropriate level of care.

Responsibilities

• Provide comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to ensure timely and appropriate discharge planning.
• Carry an appropriate caseload of select complex patients, coordinating care responsibilities with the patient care team.
• Participate in the interdisciplinary team, providing information about community-based services (e.g., indigent services, housing, social referrals, specialty care, post-acute placements, elder assistance) and offering guidance to patients and families.
• Serve as a specialist on complex psychosocial and discharge needs, end-of-life care planning, and resource needs, providing necessary information to aid patient and family decision-making.
• Partner with and serve as an expert resource to other Care Coordinators and interdisciplinary team members on complex social determinants of health, financial, legal, and situational dynamics.
• Participate in precepting new care coordinators, mentoring them on complex patient care needs and family dynamics.
• Facilitate hospital team meetings to reduce the length of stay and resource consumption for complex patient populations.
• Support leaders in negotiating agreements with community agencies and facilities.
• Perform other duties as assigned related to the hospital’s complex patient population.

Complex Disposition Planning

• Implement discharge planning and provide resource information in a timely and efficient manner for complex patients.
• Identify and document barriers for timely disposition.
• Understand eligibility processes and criteria for local, state, and federal resources to assist in safe and appropriate transitions.
• Respond to referrals for patient assistance from RNs, physicians, and the care team.
• Participate in Interdisciplinary Rounds to confirm estimated discharge dates and recommend the best level of care transition.
• Initiate/facilitate post-acute referrals through departmental processes for timely transitions.
• Provide financial needs assessments for patients requiring assistance for follow-up care.
• Advocate for and partner with patients and families to empower autonomous healthcare decisions.
• Arrange and facilitate family meetings when needed.
• Respect cultural or religious beliefs in providing service and continuity of care.

Assessment

• Initiate assessment of patients' psychosocial risk factors and resource availability upon discharge.
• Partner with PAS, financial counselors, and/or UM nurses to assess insurance and coverage requirements for all payers.
• Collaborate with patients, families, physicians, and care team members to establish and support care progression and discharge plans.

Documentation

• Complete and document initial psychosocial/functional assessments in the medical record.
• Ensure all records are up-to-date and documentation is clear and understandable.
• Document progress notes and interactions with patients/families in a timely and accurate manner.
• Account for and indicate all services arranged/delivered in the Electronic Health Record.
• Enter avoidable days, when applicable, in the Electronic Health Record.

Professional Development and Initiative

• Complete all initial and ongoing professional competency assessments and required mandatory education.
• Support departmental-based goals contributing to organizational success.
• Participate in the development of protocols, procedures, and performance improvement initiatives to optimize patient outcomes.

Precepting/Mentoring

• Assist leadership with precepting new hires as needed.
• Mentor new and less senior employees in addressing challenging situations for patients and families through the continuum of care.
• Serve as a preceptor and/or mentor for student interns.

Requirements

• Associate’s Degree in Nursing or Diploma in Nursing (Bachelor’s Degree in Nursing preferred).
• Current BLS certification (Basic Life Support, American Red Cross BLS, or BLS-Instructor).
• Active RN license (Single State or Multi-state Compact).
• Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care, or community environment in care coordination.
• Minimum 2 years of experience in care coordination in the acute care setting.

Skills

• Excellent written and verbal communication skills.
• Maturity, self-confidence, objectivity, and a positive attitude.
• Self-directed with the ability to function well under stress, handle change, and work in a fast-paced environment.
• Strong assessment, interview, organizational, and problem-solving skills.
• Knowledge of local, state, and federal regulations.
• Knowledge of community and statewide resources and programs.
• Ability to work collaboratively with physicians, care team members, and patients/families to assist through the continuum of care.

Schedule

Full-time, Day shift.