Care Coordinator - SJ

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 manage the process of assessing, planning, implementing, coordinating, monitoring, and evaluating health services for patients.

The role emphasizes discharge planning, readmission risk assessment, and collaboration with social workers throughout acute care stays. Responsibilities include daily discharge planning discussions with families, ensuring timely documentation, and active participation in multidisciplinary rounds to remove

Qualifications

• Brief assessment, readmission risk assessment, and 6-click mobility assessment within 1 business day of admission.
• Discuss discharge-planning needs with patient, family, and care team to coordinate resources.
• Reassess and document updates to discharge plan every 2 days with patient understanding or agreement.

Responsibilities

• Collaborates with Social Workers for complex-patient resolution and escalate barriers to leadership.
• Attend MDRs and provide GMLOS, actual LOS, and discharge date for daily review.
• Identify readmissions or high-risk cases and minimize avoidable days per procedure.
• Maintain communication with care team via voice mail and email at least every 2 hours; complete documentation by end of day.

Skills

Discharge planning

Readmission risk assessment

Care coordination

Collaboration

Documentation

Communication

Education

Bachelor's Degree in Nursing - Preferred

Master's Degree in Social Work - Preferred

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 health 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 of 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. Presents 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.
• Attend MDRs per department standard operating procedure. Provide 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. Prioritizes 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.
• 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.