Discharge & Care Coordination Specialist

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

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.