Care Coordinator-RN

American Geriatrics Society; Augusta (GA); On-site; USD 65,000 - 85,000; Full time

Job summary

The Care Coordinator RN (CC RN) at American Geriatrics Society assesses transitional care needs, coordinates across the continuum, and engages with patients and families to ensure care needs are met. The CC RN plans effectively to meet the patient’s needs, manage length of stay, and promote efficient utilization of resources.

Core duties include psychosocial assessment, care progression, and discharge planning, with collaboration among physicians, UM nurses, and the interdisciplinary team to

Qualifications

• Excellent written and verbal communication skills are required.
• Must be mature, self-directed, and capable under pressure.
• Strong assessment, interview, organizational, and problem-solving abilities.
• Knowledge of local, state, and federal regulations.
• Familiarity with community and statewide resources for transitions of care.

Responsibilities

• Assess chronic disease management needs and psychosocial risk factors.
• Coordinate discharge planning and post-discharge follow-up.
• Facilitate care progression and interdisciplinary rounds.
• Document interactions and ensure clinical records are current.
• Collaborate with care team, physicians, and families to meet discharge goals.

Skills

Excellent written and verbal comms

Maturity

Self-directed under stress

Care coordination & teamwork

Regulatory knowledge

Community resources knowledge

Assessment & problem solving

Education

Associates Degree in Nursing or Nursing Diploma or Bachelors in Nursing (Preferred)

Job description

Job Summary

The Care Coordinator RN (CC RN) assesses transitional care needs, coordinates care across the continuum, and engages with patients and families to ensure care needs are met. The CC RN plans effectively to meet the patient’s needs, manage length of stay, and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions. Core functions include psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitation of patient/family care conferences, participation in interdisciplinary rounds, and patient/family education. The CC RN collaborates with the utilization review nurse, physicians, and the interdisciplinary care team to provide a comprehensive assessment of medical, psychosocial, and social determinants of health needs, goal attainment, and continued care requirements. The CC RN ensures patients progress toward discharge goals, alleviates barriers, seeks consulting as needed to expedite care, and may have other duties assigned.

Core Responsibilities and Essential Functions

• Assessment: Initiates assessment of patients’ chronic disease management needs, psychosocial risk factors, and resource availability. Partners with the PAS, financial counselor, and/or UM nurse to evaluate insurance and coverage requirements for all payers. Collaborates with patients, families, physicians, and care team members to establish and support care progression and discharge plans. Meets regularly with physicians and care team to coordinate timely and efficient patient management.
• Disposition Planning: Manages all aspects of discharge planning for assigned patients, implements timely discharge planning and resource allocation, meets with patients/families to develop individualized discharge plans, identifies and documents barriers, maintains discharge plan consensus with all stakeholders, responds to referrals for post‑acute needs, participates in interdisciplinary rounds to confirm discharge timing, initiates post‑acute referrals, refers cases for social work intervention, and respects cultural or religious beliefs in service delivery.
• Care Progression: Collaborates with physicians and care team to facilitate communication regarding care progression, proactively identifies diagnostic or treatment delays that may impact discharge, discusses medical necessity for inpatient testing versus outpatient setting, and resolves barriers to discharge by escalating to appropriate leaders.
• Documentation: Completes initial clinical/psychosocial assessment in the medical record, ensures all records are current and clear, documents interactions with patients, families, physicians, and community partners, accounts for all services delivered, and tracks avoidable days to report trends.
• Professional Development and Initiative: Completes initial and ongoing competency assessments, mandatory and population‑specific education, supports department‑based goals, serves as a preceptor or mentor for student interns, performs other duties as assigned, and 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 Licenses and Certifications

All certifications are required upon hire unless otherwise stated.

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

Required Minimum Experience

Minimum 1 year nursing experience in an acute care setting.

Required Minimum Skills

• Excellent written and verbal communication skill.
• Must possess maturity, self‑confidence, objectivity, and a positive attitude.
• Self‑directed with the ability to function well under stress, handle change, and operate in a fast‑paced environment.
• Strong assessment, interview, organizational, and problem‑solving skills.
• Knowledge of local, state, and federal regulations.
• Knowledge of community and statewide resources and programs.
• Ability to work collaboratively with physicians, care team members, and patients/families to support transitions of care.