RN Care Coordinator: Transitional Care & Discharge

Wellstar Health System; Hephzibah (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

Wellstar Health System in Georgia seeks a Care Coordinator RN (CC RN) to assess transitional care needs and coordinate care across the continuum. You will engage with patients and families to ensure discharge plans align with goals, while collaborating with physicians and the care team to optimize care progression and resource utilization.

The role emphasizes psychosocial assessment, discharge planning, and effective communication within a multidisciplinary team to support patients from

Qualifications

• Excellent written and verbal communication skills.
• Ability to work under stress in a fast-paced environment.
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge of local, state, and federal regulations.
• Knowledge of community and state-wide resources and programs.
• Ability to collaborate with physicians, care team, and patient/family to progress care.

Responsibilities

• Assess transitional care needs and psychosocial risk factors.
• Coordinate discharge planning and post-acute referrals.
• Collaborate with PAS, financial counselor, and UM nurse on insurance requirements.
• Participate in interdisciplinary rounds and care conferences.
• Document clinical/psychosocial assessments in the medical record.
• Track avoidable days and report trends.
• Comply with Wellstar Health System policies.

Skills

Written communication

Verbal communication

Interpersonal skills

Assessment skills

Organizational skills

Problem-solving

Regulatory knowledge

Community resources

Team collaboration

Education

RN degree

Job description

Wellstar Health System in Georgia seeks a Care Coordinator RN (CC RN) to assess transitional care needs and coordinate care across the continuum. You will engage with patients and families to ensure discharge plans align with goals, while collaborating with physicians and the care team to optimize care progression and resource utilization.

The role emphasizes psychosocial assessment, discharge planning, and effective communication within a multidisciplinary team to support patients from