Registered Nurse (RN)-Acute Care- Care Coordination Sr. (ED 12 Hour Daytime)

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? 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.

About the Role

Come join our Cobb Hospital Care Coordination team! Full-time, day shift, 12-hour coverage in the Emergency Department. Relocation assistance available for eligible candidates.

About the Facility

Learn more about Wellstar Cobb Hospital, including our teams, culture and campus environment.

Responsibilities

• Transitional care planning, clinical care progression, psychosocial and functional status assessment
• Attending patient/family care conferences, interdisciplinary rounds, and patient/family education
• Collaborating 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, social determinants of health, goals/outcome attainment, and continued care needs
• Ensuring the patient is progressing towards their discharge goal and assisting to alleviate barriers
• Seeking consultation from appropriate disciplines/departments to proactively identify and resolve delays to expedite care and facilitate discharge
• Participating in orientation and precepting of new employee hires (as needed)
• Mentoring new hires in clinical progression/case reviews and efficient transitional/discharge planning

Assessment

• Initiates assessment of patients' psychosocial risk factors and availability of resources to assist upon discharge
• Partners with PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers
• Collaborates with the patient, family, physician(s), and care team to establish and support care progression and discharge plans
• Meets with physicians and care team routinely to collaborate on timely and efficient patient management

Care Progression

• Collaborates with physicians and care team to facilitate communication regarding patients' care progression
• 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 escalates issues to the appropriate leader for efficient resolution

Disposition Planning

• Manages all aspects of discharge planning for assigned patients
• Implements discharge planning timely and provides resources efficiently
• Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians
• Identifies and documents barriers for timely disposition
• Responds to referrals for patients' post-acute needs from physicians and the care team
• Participates in Interdisciplinary Rounds to confirm estimated date of discharge and recommend best level of care transition
• Ensures/maintains discharge plan consensus with patient/family, physicians, care teams, and payers
• Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care
• Refers appropriate cases for social work intervention based on departmental protocol
• Allows for cultural or religious beliefs in providing service and continuity of care

Documentation

• Completes and documents initial clinical/psychosocial assessment in medical record
• Ensures all records are up-to-date and documentation is clear and concise
• Ensures timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners
• Accounts for and indicates all services arranged/delivered in electronic medical record
• Tracks avoidable days and reports trends that lead to undesired outcomes

Precepting/Mentoring

• Assists leadership with precepting new hires when needed
• Mentors new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care
• Serves as a preceptor and/or mentor for student interns

Professional Development and Initiative

• Completes all initial and ongoing professional competency assessment, required mandatory education, population-specific education
• Supports department-based goals which contribute to the success of the organization
• Performs other duties as assigned
• Complies with all Wellstar Health System policies, standards of work, and code of conduct

Requirements

• 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 in care coordination in the acute care setting required
• Minimum 3 years experience as a staff nurse in an acute care hospital setting
• Minimum 2 years experience as a case manager in a hospital setting or payer-based model with expertise in case management competencies

Qualifications

• Associate's degree in Nursing or Diploma in Nursing (required)
• Bachelor's degree in Nursing (preferred)
• BLS certification (Basic Life Support, American Red Cross Basic Life Support, or Basic Life Support - Instructor)
• Registered Nurse (Single State) or RN - Multi-state Compact license

Skills

• Excellent written and verbal communication skills
• Maturity, self-confidence, objectivity, and 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 state-wide resources and programs
• Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care