About This Role
This role as a Care Coordinator RN involves assessing the transitional care needs of patients, coordinating their care across various settings, and engaging with patients and families to ensure their needs are met. The coordinator plans effectively to manage patient length of stay and promote efficient use of resources, integrating care facilitation, progression, and transitional care planning.
Responsibilities
- Initiate assessment of patients' chronic disease management needs, psychosocial risk factors, and resource availability for discharge based on preliminary screening
- Partner with the Patient Access Services (PAS), financial counselor, and/or Utilization Management (UM) nurse to assess insurance and coverage requirements for all payers
- Collaborate with the patient, family, physician(s), and other care team members to establish and support patient care progression and discharge plans
- Meet with physicians and the care team routinely to collaborate on timely and efficient patient management
- Manage all aspects of discharge planning for assigned patients
- Implement discharge planning timely and provide resources efficiently
- Meet with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians
- Identify and document barriers for timely disposition
- Ensure/maintain discharge plan consensus with patient/family, physicians, care teams, and payers
- Respond to referrals for patients' post-acute needs from physicians and the care team
- Participate in Interdisciplinary Rounds with the patient's care team to confirm estimated date of discharge and make recommendations for the best level of care transition at discharge
- Initiate/facilitate 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
- Allow for any cultural or religious beliefs in providing service and continuity of care
- Collaborate with physicians and the care team to facilitate communication regarding patient care progression to ensure timely and efficient delivery of care
- Proactively identify delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays
- Identify and discuss with the physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting
- Actively work to resolve barriers to discharge and engage/escalate barriers to discharge to the appropriate leader for efficient resolution
- Complete and document initial clinical/psychosocial assessment in the medical record
- Ensure all records are up-to-date and documentation is clear and concise
