Care Coordinator RN WMCG

locationsAU Medical Center, Inc.

time typeFull time

posted onPosted 2 Days Ago

job requisition idJR-37670

How would you like to work in a place where your contributions and ideas are valued? 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.

Job Summary:

The Care Coordinator RN (CC RN) 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 CC RN plans effectively to 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. Specific functions within this role include: Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education Collaborates 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 needs Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. May have other duties assigned Core Responsibilities and Essential Functions:

Assessment Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge. Partners with the PAS, financial counselor 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. 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. Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers. 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. 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. 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. Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution Documentation Initial clinical/psychosocial assessment completed and documented in medical record. Ensure all records are up-to-date and documentation is clear and concise. 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. Track avoidable days and report trends that lead to undesired outcomes. Professional Development and Initiative Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. Supports department-based goals which contribute to the success of the organization. Serves as a preceptor and/or mentor for student interns (if appropriate) Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education:

• Associates Nursing

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Reg Nurse (Single State) or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 1 year nursing experience in the acute care setting. Required Required Minimum Skills:

Excellent written and verbal communication skill. Must possess maturity, self-confidence, objectivity, and positive attitude. Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment Strong assessment, interview, organizational and problem-solving skills. 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 with progression of care through their transition to the next level of care.

Join us and discover the support to do more meaningful work-and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

About Wellstar At Wellstar, people are at the center of everything we do and every decision we make. As a not-for-profit organization, we have made a generational commitment to transform healthcare for all. We work to ensure every person has access to personalized care that helps them spend more time being a person, rather than a patient. That s what we mean when we say we re more than healthcare we re PeopleCare.

Wellstar is nationally recognized for our inclusive culture, exceptional doctors and team members, and personal, high-quality care. We thoughtfully reinvest in prevention, wellness programs and charity care, and provide access to compassionate, world-class care through our expansive system of 11 hospitals, 329 medical office locations, 11 cancer centers, 91 rehabilitation centers, 35 imaging centers, 20 urgent care locations, five health parks, three hospice facilities and two retirement villages. To learn more about how we care for the communities we serve, visit wellstar.org.

Mission, Vision and Values

• Our Mission is to enhance the health and well-being of every person we serve.
• Our Vision is to deliver world-class healthcare to every person, every time.
• Our Values are to serve with compassion, pursue excellence and honor every voice.

Coverage at a Glance When we say we serve the community, we mean it. Wellstar medical centers, health parks, medical offices and other facilities are conveniently located across the state of Georgia.

• 11 hospitals
• 2,729 licensed beds
• 5 health parks
• 20 urgent care locations
• 329+ medical offices
• 11 cancer centers
• 91 rehabilitation centers
• 35 imaging centers
• 3 hospice facilities
• 2 retirement villages
• 9 pediatric centers
• 11 sleep labs
• 7 wound care centers
• 10 counties offering home health services

With more than 1 million patient visits in 2023, the Wellstar Health Parks in East Cobb, Acworth, Avalon, Cherokee and Vinings provided patients with seamless care and convenient access to primary care, specialists, outpatient procedures, pharmacy, urgent care, physical therapy and imaging all at a single location. It s part of our commitment to offer access to quality healthcare at the right time and place for our patients.