Case Coordinator RN: Discharge and Care Continuum Lead

St. Vincent's Medical Center; Bridgeport (CT); On-site; USD 75,000 - 110,000; Full time

Job summary

St. Vincent’s Medical Center in Bridgeport, CT, is seeking a licensed Case Coordinator - RN to lead discharge planning within an interdisciplinary team. The role focuses on assessing patient needs, coordinating care across the continuum, and removing barriers to post-acute care access.

The ideal candidate has acute-care nursing experience, strong communication skills, and a commitment to patient-centered outcomes in a Magnet-designated hospital setting.

Qualifications

• Licensed Registered Nurse credentialed from the Connecticut Department of Public Health obtained prior to hire date or job transfer date.
• Preferred Credential(s): BLS Provider (AHA/Red Cross).
• Completion of a formal Nursing program.
• Associate’s degree hires, Nursing Baccalaureate Degree (BSN) must be obtained within 6 years of hire.
• Three years of acute-care setting, diversified clinical nursing experience, including medical/surgical nursing.
• Case management, home care, and/or managed care experience strongly considered.

Responsibilities

• Assesses patient population in collaboration with the Health Care Team, for appropriate level of care across the care continuum; identifies risk factors such as clinical, psychosocial, and/or financial indicators and determines level of case coordination; facilitates involvement of support services to promote optimal clinical and financial outcomes.
• Develops and implements discharge planning in collaboration with the Health Care Team, by monitoring plans of care, coordinating consultations/referrals, identifying referrals for appropriate level of care, collaborating with patient and family and providing clinical information to community resources to provide efficient quality care.
• Collaborates daily with direct care providers to assess in-hospital stays and to facilitate post-hospitalization services, placement, and/or transportation.
• Models’ quality patient/customer service by serving all customers at all times, maintaining and functioning in a collaborative manner with other caregivers to ensure quality patient care; maintaining awareness of patient/customer needs and responding to those needs; maintaining confidentiality of all patient information.
• Provides ongoing assessment, including gathering comprehensive information to use in developing interventions and treatment strategies.
• Optimizes client functioning through case management that facilitates collaboration among providers to address the client’s biomedical and psychosocial needs to better provide efficient, appropriate, and beneficial health care services to a client with multiple needs.
• Advocates for the needs and interests of patients including advocating for larger system change to improve access to care and improved delivery of services.
• Educates patients, families, the community, and other professionals regarding disease prevention, impact of illness and disease progression, advocacy for benefits, health maintenance, and adherence to treatment regimens.
• Maintains timely documentation of case management services which reflect the patient and client systems’ pertinent information for assessment, interventions, and outcomes.
• Provides timely assessments of needs for discharge planning for patients with prolonged length of stay.
• Identifies discharge delays throughout the hospitalization and develops countermeasures for potential barriers to discharge.
• Identifies lack of payer source and makes appropriate referrals to secure needed insurance coverage or providers for post-acute care needs.
• Identifies opportunities to decrease length of stay, reduce readmissions and improve patient experience through work in Lean huddles and participating in interdisciplinary team meetings.
• Assess patient’s readiness for discharge based on patient’s clinical status.
• Collaborates with providers to ensure appropriate patients are placed at appropriate level of care throughout their hospitalization and documentation supports patient’s present level of care.
• Performs other related duties as required.

Skills

RN licensure CT

BLS (preferred)

Case management

Communication skills

Interdisciplinary collaboration

Documentation skills

Multi-tasking

Spanish (preferred)

Education

Formal Nursing program

BSN within 6 years of hire

Job description

St. Vincent’s Medical Center in Bridgeport, CT, is seeking a licensed Case Coordinator - RN to lead discharge planning within an interdisciplinary team. The role focuses on assessing patient needs, coordinating care across the continuum, and removing barriers to post-acute care access.

The ideal candidate has acute-care nursing experience, strong communication skills, and a commitment to patient-centered outcomes in a Magnet-designated hospital setting.