RN Discharge & Care Coordination Leader

Team Member Services; Hendersonville (TN); On-site; USD 45,000 - 77,000; Full time

Job summary

AdventHealth in Hendersonville, NC is seeking a dedicated RN to join our discharge planning team. You will assess patient needs, coordinate post-acute services, and collaborate with multidisciplinary teams to ensure timely admissions and safe transitions.

The role requires strong leadership, data analysis, and communication skills, with at least 2 years of medical/hospital nursing experience; a nursing license; and the ability to navigate complex care plans in a fast-paced setting.

Qualifications

• Leadership skills are required.
• Process and outcome data analysis skills required.
• Critical thinking and problem-solving skills required.
• Ability to manage multiple tasks and prioritize levels of importance.
• Customer service skills required.
• Ability to work with people of diverse backgrounds; adaptable to change.
• Effective organizational skills.
• Computer proficiency with Outlook e-mail and electronic medical records.
• Flexible in a complex healthcare environment.
• Knowledge of community resources and post-acute care programs.
• Knowledge of clinical and social factors affecting discharge status.
• Knowledge of CMS Conditions of Participation for Discharge Planning.
• Conflict management and teamwork skills.

Responsibilities

• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Assesses readmitted patients for the patient's and family's perceived reasons for the readmission.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work. Communicates with Payors patient's needs for authorization for post-acute care as needed.
• Assesses patients' and families' wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Other duties as assigned.

Skills

Leadership

Data analysis

Critical thinking

Multitasking

Customer service

Communication across cultures

Organizational skills

Outlook proficiency

Education

Associates of Nursing

Tools

Outlook

EMR systems

Job description

AdventHealth in Hendersonville, NC is seeking a dedicated RN to join our discharge planning team. You will assess patient needs, coordinate post-acute services, and collaborate with multidisciplinary teams to ensure timely admissions and safe transitions.

The role requires strong leadership, data analysis, and communication skills, with at least 2 years of medical/hospital nursing experience; a nursing license; and the ability to navigate complex care plans in a fast-paced setting.