Patient Care Coordinator - Interventional

Assists in developing and meeting Pillar outcomes and system improvement goals as the nursing component of the care coordination model. Improves outcomes by reducing all-cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Coordinates the evaluation process of the defined patient population, serves as a liaison between referring providers and Vanderbilt providers, and develops plans for pre-admission and post-discharge care transitions. Educates patients and families using teach-back, creates customized medication grids with input from pharmacists, and supports discharge/transition planning in collaboration with multi-disciplinary teams. Participates in creating and disseminating patient education materials, and coordinates handovers with outpatient care coordinators, home health nurses, cardiac rehab, skilled nursing facilities, and other care partners. Demonstrates reflective practice to evaluate care coordination and supports protocol development based on evidence. Key capabilities include evidence-based practice, patient education, and advanced nursing assessment. This role requires a Bachelor’s degree and RN licensure with approximately 5 years of relevant experience. Vanderbilt Health offers a comprehensive benefits package and an inclusive work environment.