Care Coordination Nurse

St. Joseph Hospital & Medical Center; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Saint Joseph's Hospital and Medical Center (SJHMC) in Phoenix, AZ seeks a Care Coordination Nurse to lead discharge planning for a diverse inpatient population from birth to adult. You will orchestrate healthcare and social services, advocating for patients while balancing needs with resources.

You will document assessments, collaborate with the care team, and oversee post-acute transitions to ensure quality, cost-effective outcomes within hospital policies.

Qualifications

• Two years of acute hospital clinical experience OR a Masters degree in Case Management or nursing field in lieu of one year experience.
• Graduate of an accredited school of nursing and RN license (AZ or Compact).
• BLS certification within 90 days; knowledge of managed care and payer environment.
• Must have critical thinking and problem-solving skills; collaborate effectively with multiple stakeholders.

Responsibilities

• Completes and documents a discharge planning assessment on patients identified by the screening process; reassess and update plan as needed.
• Facilitates the development of a multidisciplinary discharge plan with the patient, family, and post-acute providers.
• Oversees and evaluates the implementation of the discharge plan.
• Collaborates with the care team to ensure progression of care and appropriate inpatient resource utilization.
• Coordinates transitions to post-acute services based on clinical needs.

Skills

Critical thinking

Problem-solving

Teamwork

Collaboration

Professional communication

Education

RN license (AZ or Compact)

Graduate of an accredited nursing school

Job description

Where You'll Work

Hello humankindness: Join a Legacy of Healing at Saint Joseph's Hospital and Medical Center (SJHMC)

Ready to make a real difference? Join SJHMC in Phoenix AZ., a 571-bed nonprofit founded by the Sisters of Mercy over 125 years ago. We're more than a hospital; we're a global destination for life-changing care, embracing patients with humankindness.

Here, your calling will flourish. We're not just a workplace; we're a community dedicated to a mission of service.

Leaders in Specialized Care:

• Barrow Neurological Institute (BNI): A world-renowned center for groundbreaking neurological research and innovative treatments.
• Norton Thoracic Institute (NTI): A national leader in advanced thoracic care with pioneering surgical techniques.
• Level I Trauma Center: One of Arizona's busiest ERs, providing immediate, comprehensive care for critically injured patients 24/7.

Why SJHMC?

Culture of Excellence & Well-being: We care for our people, fostering professional and personal growth.

Community & Collaboration: Be part of a network committed to global health and well-being.

Join a Legacy, Shape a Future: Over 20% of our patients travel internationally for our specialized care.

This is an invitation to join a family of dedicated professionals at the forefront of medical innovation, united by the power of humankindness.

Job Summary and Responsibilities

As our Care Coordination Nurse at St. Joseph's Hospital & Medical Center, you will lead comprehensive care progression and discharge planning for our diverse inpatient population (birth to adult). Leveraging your nursing expertise, you'll orchestrate the delivery of healthcare and social services, balancing patient/family needs with cost-effective resources. This role is instrumental in advocating for patients, addressing complex factors like spiritual needs and socioeconomic barriers, and ensuring seamless, equitable transitions of care.

Every day you will meticulously conduct and update discharge planning assessments, facilitating multidisciplinary collaboration for timely and smooth transitions to post-acute care settings. You'll oversee implementation of discharge plans, optimize inpatient resource utilization, identify and mitigate readmission risks, and provide essential patient education and advocacy, all while adhering to hospital policies and promoting cost-effective, quality outcomes.

To be successful in this role, you will demonstrate exceptional critical thinking, problem-solving, and professional communication skills. Your ability to thrive in a fast-paced, self-directed environment, prioritize effectively, and collaborate seamlessly within the Care Coordination Team is crucial. You must be dedicated to furthering the hospital's mission by enhancing the patient experience and ensuring optimal outcomes.

• Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly
• Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative and post acute care providers in accordance with the patients clinical or psychosocial needs, choices and available resources
• Oversees and evaluates the implementation of the discharge plan
• Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria
• Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients clinical needs

Job Requirements

Required

• Two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of one (1) year experience
• Graduate of an accredited school of nursing
• Registered Nurse: AZ or Compact license
• American Heart Association Basic Life Support (BLS), within 90 days
• Knowledge of managed care and payer environment
• Must have critical thinking and problem-solving skills
• Collaborate effectively with multiple stakeholders
• Understand how utilization management and case management programs integrate
• Ability to work as a team player and assist other members of the team where needed
• Knowledge of CMS standards and requirements

Preferred

• Bachelor's Degree in Nursing (BSN) or related healthcare field
• At least five (5) years of nursing experience
• Certified Case Manager (CCM) or Accredited Case Manager (ACM-RN)