Care Coordinator/Discharge Planner RN - Acute Care- Med Surg
Company: Wellstar Health System, Inc.
Location: Hurdle Mills
Posted on: February 15, 2025
|
|
|
Job Description:
Facility: Paulding HospitalJob Summary:Fulltime RN/Care
Coordinator for Med Surg /Acute CareDischarge Planning inpatient 28
bed med surg unit
The Care Coordinator RN Sr. (RN Sr) 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 most complex cases during the patient's acute admission. The RN
Sr requires strong clinical expertise to partner with physicians
and care teams to drive optimal and efficient treatment plans to
streamline progression of care while in the hospital, as well as,
planning for post discharge care. The RN Sr will serve as an expert
resource and consultant to the other team members in regards to
care progression and assisting in planning to effectively 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:
Transitional care planning, clinical care progression, psychosocial
and functional status assessment, attending patient/family care
conferences, 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.
Will participate in orientation and precepting of new employee
hires (as needed). The RN Sr will mentor new hires in clinical
progression/case reviews and efficient transitional/discharge
planning.
May have other duties assigned.Core Responsibilities and Essential
Functions:
__Assessment__
Based on preliminary screening of patients, initiates assessment of
patients psychosocial risk factors and availability of resources to
assist upon discharge.
Partners with the PAS, financial counselors, 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.
__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
__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.
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.
Ensures/maintains discharge plan consensus with patient/family,
physicians, care teams and payers.
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.
__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.
__Precepting/Mentoring__
Assist leadership with precepting new hires when needed.
Mentoring new and less senior employees in addressing challenging
situations in assisting patients/families through the continuum of
care.
Serves as a preceptor and/or mentor for student interns
__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.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of
work, and code of conduct.Required Minimum Education:
Bachelor's Degree in Nursing from an accredited school of nursing
RequiredRequired Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise
stated.
Minimum 3 years experience as a staff nurse in an acute care
hospital setting. Required and
Minimum 2 years experience as a case manager in a hospital setting
or payer-based model with expertise in case management competencies
and to guide the care team through complex discussions.
RequiredRequired 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 through the continuum
of care.Required
Keywords: Wellstar Health System, Inc., Burlington , Care Coordinator/Discharge Planner RN - Acute Care- Med Surg, Healthcare , Hurdle Mills, North Carolina
|
Click
here to apply!
|
