Care Coordination Nurse: Inpatient Rehab & Transitions

CommonSpirit Health; Phoenix (AZ); On-site; USD 54,000 - 80,000; Full time

Job summary

Saint Joseph’s Hospital and Medical Center in Phoenix, AZ is seeking a Care Management Professional to guide patients through complex healthcare journeys, coordinating resources and developing individualized care plans. You will educate patients and collaborate with multidisciplinary teams to ensure continuity of care and prevent readmissions.

Qualified candidates have nursing or social work degrees, AZ licensure, and several years of case management or social work experience in inpatient rehab

Qualifications

• Bachelors of Nursing or Masters in Social Work from an accredited university and job related experience
• Registered Nurse: AZ or Licensed Clinical Social Worker: AZ or Social Worker: AZ
• Four years experience as a Case Manager or Social Worker in an inpatient rehabilitation setting
• Certified Rehabilitation Registered Nurse (CRRN)

Responsibilities

• Completes psycho-social assessments to gather pertinent information for the team regarding patient adjustment, family support, financial resources, housing, understanding of disability and barriers to discharge
• Incorporates patient's psychosocial status and diagnosis in evaluating treatment plan for appropriateness, in collaboration with the physiatrist and interdisciplinary team.
• Ensures that patient-centered goals are collaboratively established within the interdisciplinary team
• Provides team with pertinent financial information to facilitate decision making through the following processes: Intake; Evaluation; Planning: the Provision of Services; Discharge/Transition Planning; and Long Term Follow-up to ensure appropriate use of patient care resources and their financial impact on the service line and that resource utilization is congruent with life-planning of the individual
• Monitors patient and family goal attainment relative to the interdisciplinary treatment plan and addresses the appropriateness of the level of care during Team Rounds. Intervenes when variances occur in a patient's individualized treatment plan
• Facilitates Team Rounds and interdisciplinary documentation.

Skills

Assessment skills

Care coordination

Communication

Education

Bachelor's in Nursing

Master's in Social Work

Job description

Saint Joseph’s Hospital and Medical Center in Phoenix, AZ is seeking a Care Management Professional to guide patients through complex healthcare journeys, coordinating resources and developing individualized care plans. You will educate patients and collaborate with multidisciplinary teams to ensure continuity of care and prevent readmissions.

Qualified candidates have nursing or social work degrees, AZ licensure, and several years of case management or social work experience in inpatient rehab