RN Complex Care Navigator: Discharge & Transitions

Wellstar Health System; Austell (GA); On-site; USD 75,000 - 95,000; Full time

Job summary

Wellstar Health System is seeking an RN Complex Care Coordinator to assess and coordinate complex patient transitions, ensuring safe discharge plans across care settings. You will work with patients and families, and collaborate with the care team to address psychosocial, financial, and resource needs.

The role focuses on high-risk, high-cost patients, with responsibilities in precepting, interdisciplinary rounds, and community referrals to optimize outcomes and reduce readmissions.

Qualifications

• All certifications are required upon hire unless otherwise stated.
• Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination.
• Minimum 2 years in care coordination in the acute care setting.

Responsibilities

• Implements discharge planning and provides resource information in a timely and efficient manner for complex patients.
• Identifies and documents barriers for timely disposition.
• Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
• Responds to referrals for patient assistance from RN physicians and the care team.
• Participates in Interdisciplinary Rounds with the patient care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.
• Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.
• Provides financial needs assessment for patients requiring assistance for follow‑up care throughout the continuum.
• Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning.
• Arranges and facilitates family meetings when needed.
• Allows for any cultural or religious beliefs in providing service and continuity of care.

Skills

Excellent communication

Maturity and professionalism

Stress management

Adaptability

Team collaboration

Knowledge of regulations

Care coordination experience

Education

Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-Preferred

Job description

Wellstar Health System is seeking an RN Complex Care Coordinator to assess and coordinate complex patient transitions, ensuring safe discharge plans across care settings. You will work with patients and families, and collaborate with the care team to address psychosocial, financial, and resource needs.

The role focuses on high-risk, high-cost patients, with responsibilities in precepting, interdisciplinary rounds, and community referrals to optimize outcomes and reduce readmissions.