RN Complex Care Navigator: Discharge & Transitions

Wellstar Health System; Blythe (GA); On-site; USD 70,000 - 95,000; Full time

Job summary

Wellstar Cobb Hospital is seeking an RN Complex Care Coordinator to assess complex patient needs, coordinate care across the continuum, and ensure a timely, safe discharge plan with patients and families.

The role includes conducting comprehensive psychosocial assessments, partnering with the care team to address barriers, and guiding patients toward appropriate post-acute placement while leveraging community resources.

Qualifications

• Must be a licensed RN in the state where employed.
• Experience coordinating care for complex patients and discharge planning.
• Strong communication with patients, families and care teams.
• Knowledge of community resources and social determinants of health.

Responsibilities

• Perform comprehensive clinical and psychosocial assessments for high-risk patients.
• Coordinate multidisciplinary care and discharge planning across settings.
• Identify barriers to timely disposition and coordinate with resources to address them.
• Educate and mentor other care coordinators and participate in team rounds.
• Facilitate family meetings and document care plans in the EHR.

Skills

Care coordination

Discharge planning

Complex patient assessment

Interdisciplinary teamwork

Resource navigation

Education

RN license

BSN (preferred)

Tools

EHR (Electronic Health Record)

Job description

Wellstar Cobb Hospital is seeking an RN Complex Care Coordinator to assess complex patient needs, coordinate care across the continuum, and ensure a timely, safe discharge plan with patients and families.

The role includes conducting comprehensive psychosocial assessments, partnering with the care team to address barriers, and guiding patients toward appropriate post-acute placement while leveraging community resources.