Care Coordinator - CH

St. Joseph's/Candler; Savannah (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Joseph's/Candler in Savannah, GA seeks a Care Coordinator to lead the interdisciplinary process coordinating medical and psychosocial needs, monitor length of stay, and ensure safe, cost-effective discharge planning across the care team.

The role requires nursing or social work experience, licensure in the state, and preferred case management credentials; strong communication and collaboration with patients, families, and clinicians are essential.

Qualifications

• Bachelor's Degree in Nursing - Preferred or Master's Degree in Social Work - Preferred
• 1-2 Years nursing or social work experience - Required
• 3-5 Years case management experience in acute care - Preferred
• Professional License with State of Practice - Required for Nurse; Preferred for Social Worker
• National Certification in Case Management - Preferred

Responsibilities

• Performs brief assessment, readmission risk assessment, and 6 clicks mobility assessment within one business day of admission.
• Discuss discharge-planning needs with patient, family, and care team to determine most effective coordination of resources.
• Reassess and document updates to discharge plan every 2 days including patient understanding or refusal of plan.
• Collaborates with Social Workers for complex-patient problem resolution and resolves discharge issues through team communication.
• Schedule regular family conferences and present high-risk complex patients at LOS/Complex Care rounds with CCC leadership.
• Identify readmissions or high-risk cases and take actions to minimize avoidable days.
• Interact with Utilization Management and attending physicians to review admission status and prevent inpatient denials.
• Identify anticipated discharge date daily and provide insights during MDRs.
• Maintain communication with care team via voice mail/email every 2 hours and provide handoffs during transitions.

Skills

communication

care coordination

discharge planning

team collaboration

Education

Bachelor's degree in nursing

Master's degree in social work

Job description

• The Care Coordinator assumes responsibility and accountability for the collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s medical and psychosocial needs, using communication and available resources to insure quality, cost-effective outcomes. Closely monitors length of stay for all assigned patients.
• Education
• Bachelor's Degree in Nursing - Preferred or Master's Degree in Social Work - Preferred
• Experience
• 1-2 Years if nursing or social work experience - Required
• 3 - 5 Years of case management experience in acute care setting - Preferred
• License & Certification
• Professional License with State of Practice - Required for Nurse; Preferred for Social Worker
• National Certification in Case Management - Preferred
• Core Job Functions
• Performs brief assessment, readmission risk assessment, and 6 clicks mobility assessment within one business day of admission. Discuss discharge-planning needs with patient, family, and care team to determine most effective coordination of resources. Ensures patient/family/caregiver is aware of and agreeable to expected day of discharge. Reassess and document updates to discharge plan every 2 days including patient understanding or refusal of plan.
• Collaborates with Social Workers for complex-patient problem resolution. Resolves outstanding or unanticipated discharge issues through communication with patient, family, and care team. Schedule regular family conferences to maintain communication. Present and discuss high-risk complex patients at high risk LOS / Complex Care rounds with CCC leadership. Discuss barriers with the attending physician and if unsuccessful, escalate to leadership and Physician Advisor.
• Attends MDRs per department standard operating procedure. Provides GMLOS, actual LOS, and expected date of discharge for every patient each day. Focus MDR team’s attention on identifying barriers to discharge and creating plan of action to address the barriers. Provide insights on appropriate patients status and level of care. Review action items created during MDRs at the daily 2pm touchpoint meetings to determine resolution versus need for additional action
• Identifies patients who are readmissions or at high risk of extending their stay beyond the GMLOS and take actions to minimize avoidable days. Documents avoidable days per department standard operating procedure.
• Proactively interacts with Utilization Management team and attending physicians to review admission status and prevent inpatient denials. Prioritize review of SDC and Observation patients to determine if ready for discharge. Follows payer requirements and government regulations to ensure compliant, safe, and cost-effective care.
• Identify anticipated discharge date for each patient each day. Provide insights on appropriate patient status and level of care throughout the patient stay to care team members during MDRs. Focus care team's attention on discharge planning, outliers and potential outliers. Present and discuss medical plan and transition plan of assigned patients at high risk LOS meetings.
• Maintains communication with care team by checking voice mail and email at minimum every 2 hours, completes required documentation by the end of the workday, adheres to on-call schedule and works holidays/covers weekend WOW absences as scheduled, and provides handoffs by email to team members as patients transition through the continuum of care. Provides weekend / on-call / PTO handoff.