Registered Nurse; RN -Care Coordinator

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)

• The Care Coordinator RN (CC RN) 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 CC RN plans effectively to 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:
• Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in 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.
• May have other duties assigned

• Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.
• Partners with the PAS, financial counselor 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.

• 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 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.

• 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.
• Identities 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

• Initial clinical/psychosocial assessment completed and documented in medical…