Registered Nurse (RN) Care Coordinator

101 Riverside Hospital, Inc.; United States; On-site; USD 80,000 - 110,000; Full time

Job summary

Riverside Health System in Newport News, VA seeks an experienced RN Care Manager for discharge planning. You will lead transitions from admission to post-discharge, coordinating care with the interdisciplinary team, families, and community resources.

Responsibilities include comprehensive assessments, developing individualized discharge plans, and ensuring CMS compliance. Prior ACMA/ CCM experience is a plus; offers include robust benefits and growth opportunities.

Qualifications

• Proven ability to plan safe discharge for patients.
• Experience coordinating across care settings.
• Familiarity with ACMA/ CCM qualifications is preferred.

Responsibilities

• Lead discharge planning from admission through post-discharge follow-up.
• Conduct comprehensive assessments of patients' clinical and social needs.
• Develop, implement and update individualized, cost-effective discharge plans.

Skills

Discharge planning

Care coordination

Interdisciplinary collaboration

Education

Nursing Diploma

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

Newport News, Virginia

Hiring Range $38.60 - $53.08/Hourly

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)

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.