Registered Nurse (RN) Care Coordinator

Overview

Works under the supervision of department leadership and collaborates with the healthcare team to coordinate patient care across the continuum. Promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical, and resource outcomes. Provides a comprehensive range of services in accordance with Riverside Health System standards of excellence and utilizes national hospital‑based ACMA Scope of Services and Standards of Practice as the foundation of care management.

Responsibilities

• Lead discharge planning from admission through post‑discharge follow‑up.
• Conduct comprehensive assessments of patients’ clinical, psychosocial, and discharge planning needs.
• Develop, implement, and update individualized and cost‑effective discharge plans.
• Utilize sequencing of interventions for safe, timely, efficient, effective, equitable, and patient‑centered transitional planning.
• Coordinate safe and timely transitions to appropriate levels of care, including home, skilled nursing facilities, acute rehab, and behavioral health.
• Collaborate with the interdisciplinary team, patients, families/support systems, payers, and community resources to ensure smooth transitions of care.
• Act as a liaison between the clinical team, patients and families, and external agencies in developing safe discharge plans.
• Participate in daily rounds, case conferences, family meetings, weekly outlier case reviews, and multidisciplinary team meetings, communicating discharge updates clearly and proactively.
• Ensure compliance with federal and state discharge planning regulations, in accordance with CMS Conditions of Participation.
• Monitor length of stay and identify/resolve barriers to timely discharge.
• Maintain accurate, timely, and compliant documentation in the medical record to promote transparency and open communication.
• Stay current on care management best practices, regulatory changes, and payer requirements (Medicare, Medicaid, managed care, etc.).
• Deliver all required notices (e.g., Important Message from Medicare, Medicare Outpatient Observation Notice) according to CMS guidelines.
• Promote patient‑centered care and shared decision‑making in discharge planning.
• Educate patients and families on treatment plans, discharge options, and available resources.
• Place referrals to complex case management as needed.
• Participate in quality‑improvement initiatives related to readmissions, throughput, and patient outcomes.
• Identify and document internal and external avoidable days.
• Serve as a resource to fellow non‑clinical care coordinators and assist with appropriate discharge planning as necessary.

Qualifications

• Education
  • Nursing Diploma Program – Required
  • Associate’s Degree in Nursing – Required
  • Bachelor’s Degree in Nursing – Preferred
• Experience
  • 3–4 years clinical experience (may include LPN experience) – Required
  • 1 year case management experience – Preferred
• Licenses and Certifications
  • Registered Nurse (RN) – Virginia Department of Health Professions (VDHP) – Upon hire – Required
  • Accredited Case Manager (ACM) – American Case Management Association (ACMA)/CCM – Upon hire – Preferred

Pay

Hiring range: $38.60 – $53.08 per hour. Actual pay is determined based on job‑related factors such as relevant experience, education, credentials, skills, internal equity, and business needs.