Senior Care RN Registered Nurse

Wellstar Health Systems, Inc.; Smyrna (GA); Vor Ort; USD 85.000 - 110.000; Vollzeit

Benefits dieser Stelle

Relocation assistance

Zusammenfassung

Wellstar Cobb Hospital seeks an RN Senior Care Coordinator to assess transitional care needs, coordinate across the continuum, and engage patients and families to ensure optimal discharge plans. The role requires strong clinical expertise and collaboration with physicians and care teams to streamline care progression during hospitalization, with mentoring duties for new staff.

Relocation assistance for eligible candidates is provided.

Qualifikationen

• Minimum 3 years of healthcare experience in acute care, care coordination preferred.
• 2+ years in care coordination in acute care; strong clinical expertise required.
• Knowledge of regulatory requirements and discharge planning processes.

Aufgaben

• Assess transitional care needs and coordinate across the care continuum.
• Engage with patient and family to ensure discharge planning and goals.
• Mentor new hires and guide care progression and efficient resource use.
• Collaborate with physicians, PAS, financial counselors, and UM nurses.
• Lead interdisciplinary rounds and document care progression in EMR.

Kenntnisse

Care coordination

Nursing clinical

Discharge planning

Interdisciplinary collaboration

Communication skills

Ausbildung

RN licensure (US)

Associate degree in Nursing or Diploma

Bachelor's in Nursing (preferred)

Jobbeschreibung

A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work ShiftCome join our Cobb Hospital Care Coordination team!

About the FacilityLearn more about

Wellstar Cobb Hospital

, including our teams, culture and campus environment:

Hours: FT Days 12 hour shift covering the Emergency Department

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 required.Relocation assistance for eligible candidatesThe Care Coordinator RN Sr. (RN Sr) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met the most complex cases during the patient's acute admission. The RN Sr requires strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans to streamline progression of care while in the hospital, as well as, planning for post discharge care. The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family educationCollaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needsSeeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.The RN Sr will mentor new hires in clinical progression/case reviews and efficient transitional/discharge planning.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge.Partners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans.Meets with physicians and care team routinely to collaborate on timely and efficient patient management.__Care Progression__Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.Disposition Planning__Manages all aspects of discharge planning for assigned patients.Implements discharge planning timely and provides resources in an efficient manner.Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.Identifies and documents barriers for timely disposition.Responds to referrals for patients post-acute needs from physicians and the care team.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.Refer appropriate cases for social work intervention based on departmental protocol.Allows for any cultural or religious beliefs in providing service and continuity of care.__Initial clinical/psychosocial assessment completed and documented in medical record.Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patients discharge plan.Accounts for and indicates all services arranged/delivered in electronic medical record.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care.Complies with all Wellstar Health System policies, standards of work, and code of conduct.

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

RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

Minimum 3 years experience as a staff nurse in an acute care hospital setting. Minimum 2 years experience as a case manager in a hospital setting or payer-based model with expertise in case management competencies and to guide the care team through complex discussions. Knowledge regarding local, state and federal regulations required.Knowledge of community and state-wide resources and programs.Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

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