Registered Nurse; RN Care Coordinator PRN Level 3

Overview

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.

Work Shift
Day (United States of America)

Job Summary

PRN Care Coordinator/Discharge Planner for 124 bed Paulding Hospital - acute care discharge planning. Day shift supplemental PRN as needed.

The Care Coordinator RN Sr. (RN Sr) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met the most complex cases during the patient's acute admission. The RN Sr requires strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans to streamline progression of care while in the hospital, as well as planning for post discharge care.

The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively meet the patient s needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.

Specific functions within this role include
:

• Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family education
• Collaborates effectively 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, any social determinants of health needs, goals/outcome attainment and continued care needs
• Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers
• Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge
• Will participate in orientation and precepting of new employee hires (as needed). The RN Sr will mentor new hires in clinical progression/case reviews and efficient transitional/discharge planning
• May have other duties assigned

Core Responsibilities and Essential Functions

• Assessment
  —Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. Partners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those 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.
• 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.
• Disposition Planning
  —Manages all aspects of discharge planning for assigned patients. Implements discharge planning timely and provides resources in an efficient manner. Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians. Identifies and documents barriers for…