Transitional Care RN: Discharge & Care Coordination

Wellstar Health System, Inc.; Roswell (GA); On-site; USD 65,000 - 85,000; Full time

Job summary

Wellstar Health System, Inc. is seeking a Care Coordinator RN (CC RN) to assess transitional care needs, coordinate across the continuum, and engage with patients and families to ensure care needs are met.

The role focuses on discharge planning, care progression, and coordination with the care team to optimize resources and outcomes. The CC RN collaborates with physicians, utilization review, and social work to create individualized discharge plans, address barriers, and advance patients toward

Qualifications

• Excellent written and verbal communication.
• Strong assessment, interview, organizational and problem-solving skills.
• Knowledge of regulations and community resources.
• Able to work collaboratively with physicians and care teams.

Responsibilities

• Initiate assessment of chronic disease management and psychosocial risk factors.
• Coordinate discharge planning and post-acute referrals.
• Collaborate with physicians and care team to support care progression and discharge.
• Ensure timely and accurate documentation in medical records.

Skills

Communication

Nursing assessment

Care coordination

Interdisciplinary collaboration

Documentation

Education

Associates/Diploma/Bachelor’s in Nursing

Job description

Wellstar Health System, Inc. is seeking a Care Coordinator RN (CC RN) to assess transitional care needs, coordinate across the continuum, and engage with patients and families to ensure care needs are met.

The role focuses on discharge planning, care progression, and coordination with the care team to optimize resources and outcomes. The CC RN collaborates with physicians, utilization review, and social work to create individualized discharge plans, address barriers, and advance patients toward