RN Care Coordinator: Discharge & Transitions Lead

Wellstar Health System, Inc.; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Wellstar Health System, Inc. seeks a Care Coordinator RN to assess transitional care needs and coordinate care across the continuum.

You will engage with patients and families to ensure discharge readiness and optimize resource utilization, while collaborating with physicians and the care team to advance care progression. The role emphasizes discharge planning, psychosocial assessment, and active participation in interdisciplinary rounds to facilitate timely transitions of care.

Qualifications

• Associates degree in nursing or nursing diploma required.
• RN license in state or compact
• BLS certification required
• Minimum 1 year of nursing experience in acute care
• Excellent written and verbal communication
• Maturity, self‑confidence and ability to handle stress
• Knowledge of regulations and community resources
• Ability to collaborate with physicians and care team to progress care and discharge plans

Responsibilities

• Initiate assessment of patients' chronic disease management needs and psychosocial risk factors.
• Coordinate discharge planning with care team, PAS, financial counselor, and UM nurse.
• Collaborate with patient/family and physicians to establish care progression and discharge plans.
• Meet with physicians and care team to optimize patient management and discharge timelines.
• Discharge planning management and timely execution of resources.
• Document barriers and ensure discharge plan consensus among patient, family, physicians, and payers.
• Refer appropriate cases for social work and intervene as needed to resolve barriers to discharge.

Skills

Excellent communication

Ability to work under pressure

Interdisciplinary collaboration

Assessment and problem‑solving

Regulatory knowledge

Organizational skills

Education

Associate Degree in Nursing

Nursing Diploma

Bachelor of Science in Nursing (preferred)

Job description

Wellstar Health System, Inc. seeks a Care Coordinator RN to assess transitional care needs and coordinate care across the continuum.

You will engage with patients and families to ensure discharge readiness and optimize resource utilization, while collaborating with physicians and the care team to advance care progression. The role emphasizes discharge planning, psychosocial assessment, and active participation in interdisciplinary rounds to facilitate timely transitions of care.