Registered Nurse (RN) - Care Coordinator - Full-Time Day Shift

Job Summary

Wellstar North Fulton Hospital has an opportunity for a RN Care Coordinator. Full-time Day shift.

Specific Functions

• Pyschosocial 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
• 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
• Meets with physicians and care team routinely to collaborate on timely and efficient patient management
• 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
• 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
• Allows for any cultural or religious beliefs in providing service and continuity of care
• 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

Associate's Degree in Nursing from an accredited school of nursing with a Georgia RN License Required

Required Minimum License(s) And Certification(s)

• Reg Nurse (Single State) or RN - Multi-state Compact
• BLS - Instructor

Additional License(s) And Certification(s)

Required Minimum Experience: Minimum 1 year nursing experience in the acute care setting.