Care Coordinator - Registered Nurse (RN)

4610 West Georgia Medical Center, Inc.; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Wellstar Health System, Inc. seeks a Care Coordinator RN to assess transitional care needs and coordinate care across the continuum.

You will engage with patients and families to ensure discharge readiness and optimize resource utilization, while collaborating with physicians and the care team to advance care progression. The role emphasizes discharge planning, psychosocial assessment, and active participation in interdisciplinary rounds to facilitate timely transitions of care.

Qualifications

• Associates degree in nursing or nursing diploma required.
• RN license in state or compact
• BLS certification required
• Minimum 1 year of nursing experience in acute care
• Excellent written and verbal communication
• Maturity, self‑confidence and ability to handle stress
• Knowledge of regulations and community resources
• Ability to collaborate with physicians and care team to progress care and discharge plans

Responsibilities

• Initiate assessment of patients' chronic disease management needs and psychosocial risk factors.
• Coordinate discharge planning with care team, PAS, financial counselor, and UM nurse.
• Collaborate with patient/family and physicians to establish care progression and discharge plans.
• Meet with physicians and care team to optimize patient management and discharge timelines.
• Discharge planning management and timely execution of resources.
• Document barriers and ensure discharge plan consensus among patient, family, physicians, and payers.
• Refer appropriate cases for social work and intervene as needed to resolve barriers to discharge.

Skills

Excellent communication

Ability to work under pressure

Interdisciplinary collaboration

Assessment and problem‑solving

Regulatory knowledge

Organizational skills

Education

Associate Degree in Nursing

Nursing Diploma

Bachelor of Science in Nursing (preferred)

Job description

Job Summary:

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

Core Responsibilities and Essential Functions:

• 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 record.
• Ensure all records are up-to-date and documentation is clear and concise.
• Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patients discharge plan.
• Accounts for and indicates all services arranged/delivered in electronic medical record.
• Track avoidable days and report trends that lead to undesired outcomes.
• Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.
• Supports department-based goals which contribute to the success of the organization.
• Serves as a preceptor and/or mentor for student interns (if appropriate) Performs other duties as assigned.
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Associates Nursing or Diploma (Nurse)
• Nursing or Bachelors Nursing-Preferred

Required Minimum License(s) and Certification(s):

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
• BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor

Required Minimum Experience:

• Minimum 1 year nursing experience in the acute care setting.

Required Minimum Skills:

• Excellent written and verbal communication skill.
• Must possess maturity, self-confidence, objectivity, and positive attitude.
• Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment.
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge regarding local, state and federal regulations required.
• Knowledge of community and state-wide resources and programs.
• Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist with progression of care through their transition to the next level of care.

Mission, Vision & Values

At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery.

OUR MISSION: To enhance the health and well-being of every person we serve.

OUR VISION: Deliver world-class healthcare to every person, every time.

OUR VALUES: We serve with compassion We pursue excellence We honor every voice

Culture of Excellence Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care. Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality. Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.