Registered Nurse (RN) -Acute Care - Care Coordination -Complex caseFT Days

Job Summary

Required Qualifications

• •Registered Nurse (RN)
• •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
• •Ability to assess complex patient transitional care needs
• •Ability to coordinate care across the continuum
• •Ability to engage with patient and family to assure care needs are met
• •Ability to serve as an expert resource for complex patient and situations
• •Ability to serve as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs
• •Ability to assess, coordinate, and implement a timely, safe patient discharge plan
• •Strong clinical expertise
• •Strong social expertise
• •Ability to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available
• •Ability to provide comprehensive clinical and psychosocial assessments for complex patients
• •Ability to provide timely and appropriate planning to advance the discharge plan
• •Ability to carry appropriate caseload of select complex patients
• •Ability to provide all care coordination responsibilities in coordination with the patient care team
• •Ability to participate in the interdisciplinary team
• •Ability to provide information about community-based service offerings
• •Ability to offer guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics
• •Ability to serve as a specialist on issues related to complex psychosocial and discharge needs
• •Ability to provide resource information necessary to aid patient/families in decision making up to and including support for end of life
• •Ability to partner and serve as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs
• •Ability to participate in precepting of new care coordinators
• •Ability to teach and expose new care coordinators to the most complex patient care needs and family dynamics
• •Ability to mentor other care coordinators in case reviews and discussion of difficult situations
• •Ability to facilitate hospital team meetings
• •Ability to negotiate agreements with community agencies and facilities
• •Ability to implement discharge planning and provide resource information in a timely and efficient manner for complex patients
• •Ability to identify and document barriers for timely disposition
• •Ability to understand eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge
• •Ability to respond to referrals for patient assistance from RN physicians and the care team
• •Ability to participate 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
• •Ability to initiate/facilitate post-acute referrals through departmental processes for timely transition to the next level of care
• •Ability to provide financial needs assessment for patients requiring assistance for follow-up care throughout the continuum
• •Ability to advocate and partner with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning
• •Ability to arrange and facilitate family meetings when needed
• •Ability to allow for any cultural or religious beliefs in providing service and continuity of care
• •Ability to initiate assessment of patients psychosocial risk factors and availability of resources to assist upon discharge
• •Ability to partner with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements
• •Ability to collaborate 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
• •Ability to complete all initial and ongoing professional competency assessment, required mandatory education, population specific education
• •Ability to support departmental- based goals which contribute to the success of the organization
• •Ability to participate in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes
• •Ability to assist leadership with precepting new hires when needed
• •Ability to mentor new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care
• •Ability to serve as a preceptor and/or mentor for student interns
• •FT Days availability