Registered Nurse (RN) Care Coordinator

Riverside Regional Medical Center; Newport News (VA); On-site; USD 80,000 - 110,000; Full time

Job summary

Riverside Health System in Newport News, VA is seeking a Registered Nurse to lead discharge planning across the care continuum. You will assess patient needs, develop cost-effective discharge plans, and coordinate transitions to appropriate care settings.

The role emphasizes collaboration with the care team, patients and families, with attention to CMS regulations and quality outcomes.

Qualifications

• 3-4 years clinical experience required.
• 1 year case management experience preferred.
• RN licensure in Virginia or eligible upon hire.
• ACM certification preferred upon hire.

Responsibilities

• Lead discharge planning from admission through post-discharge follow-up.
• Conduct comprehensive assessments of patients' clinical and psychosocial needs.
• Develop, implement and update individualized discharge plans.
• Coordinate transitions to home, SNF, acute rehab, or behavioral health.
• Collaborate with the interdisciplinary team, patient and family for safe planning.
• Attend rounds, case conferences and family meetings; communicate updates clearly.
• Ensure CMS and state discharge planning compliance and accurate documentation.
• Educate patients and families on treatment plans and options.

Skills

Clinical experience

Case management

Discharge planning

Interdisciplinary collaboration

Education

Nursing diploma or equivalent

Associate degree in nursing

Bachelor's degree in nursing

Job description

Newport News, Virginia Hiring Range $38.60 - $53.08/Hourly Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs.

Overview

Works under the supervision of the department leadership and is responsible for working in collaboration with the healthcare team to coordinate the care and service to patients across the continuum of care, promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical and resource outcomes. Works to provide a comprehensive range of services or clinical care associated with and in accordance with standards of excellence established by Riverside Health system and facility goals and strategic plans. Utilizes national hospital based ACMA Scope of Services and Standards of Practice as foundation of Care Management.

What you will do

Lead discharge planning from admission through post-discharge follow-up. Conduct comprehensive assessments of patients’ clinical, psychosocial, and discharge planning needs. Develop, implement, and update individualized and cost-effective discharge plans. Utilizes sequencing of interventions for safe, timely, efficient, effective, equitable, and patient-centered transitional planning. Coordinate safe and timely transitions to appropriate levels of care including but not limited to home, skilled nursing facility, acute rehab, and behavioral health. Collaborate with the interdisciplinary team, patient, their family/support system, payers, and community resources to ensure a smooth transition of care. Act as a liaison between the clinical team, patient and family, and any external agencies in the development of safe discharge plans. Participate in daily rounds, case conference, family meetings, weekly outlier case reviews, and multidisciplinary team meetings, communicating discharge updates clearly and proactively to all stakeholders. Ensure compliance with federal and state discharge planning regulations, in accordance with CMS’ Conditions of Participation. Monitor length of stay and identify/resolve barriers to timely discharge. Promote transparency and open communication by maintaining accurate, timely, and compliant documentation in the medical record. Maintain current knowledge of care management best practices and regulatory changes and understand Medicare/Medicaid, managed care, and other payer requirements. Delivers all notices (i.e. Important Message from Medicare, Medicare Outpatient Observation Notice) appropriately and according to CMS regulatory guidelines. Promote patient-centered care and shared decision-making in the development of appropriate discharge plans. Educate patients and families on treatment plans, discharge options, and available resources. Places referrals to complex case management as needed. Participate in quality improvement initiatives related to readmissions, throughput, and patient outcomes. Identify and document internal and external avoidable days. Act as a resource to fellow non-clinical care coordinators and assist with appropriate discharge planning as necessary.

Qualifications

Education Program Graduate, Nursing - Diploma Program (Required) or Associates Degree, Nursing (Required) or Bachelors Degree, Nursing (Preferred) Experience 3-4 years Clinical experience required (may include LPN experience) (Required) 1 year Case management experience (Preferred)

Licenses and Certifications

Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required) Accredited Case Manager (ACM) - American Case Management Association (ACMA)/CCM Upon Hire (Preferred)

About us

To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers. If loving your work is important to you, consider a career at Riverside. By joining our team, you can make a difference in people's lives. Our mission is to care for others as we would care for those we love. We extend that sense of caring to every patient, resident and customer, as well as to each member of our team. We offer care at all stages of life, in hundreds of locations, giving you room to grow your career, along with great benefits and perks. At Riverside Health, your trust and safety are our top priorities.