Care Coordinator RN

Assess, plan, and facilitate comprehensive care across the continuum by completing discharge planning assessments and updating patient plans as needed. Develop multidisciplinary discharge plans by engaging health team members, patients, and post-acute providers to ensure timely transitions. Oversee plan implementation, collaborate with the healthcare team to utilize inpatient resources based on evidence-based guidelines, and mitigate readmission risks for at least 30 days. Ensure smooth transitions to appropriate post-acute settings aligned with clinical needs.