Role: Complex Care Coordinator, responsible for assessing and managing the care needs of high-risk, complex patients to ensure safe and effective discharge planning and care transitions.
Responsibilities include: Conducting comprehensive clinical and psychosocial assessments, coordinating care across the continuum, facilitating timely discharges, and collaborating with interdisciplinary teams. Serving as a resource on social determinants of health, resource needs, and end-of-life planning, while mentoring new staff and precepting interns.
Key duties: Implementing discharge plans, identifying barriers to timely disposition, assessing insurance and resource requirements, documenting assessments and interventions, and advocating for patient-centered care. Facilitating family meetings and integrating cultural or religious considerations are also essential.
Qualifications: Minimum of an Associate’s or Bachelor’s Nursing degree, valid RN license, and certifications such as BLS. Requires at least 3 years of healthcare experience, including 2 years in care coordination within an acute care setting.
Skills: Excellent communication, assessment, organizational, and problem-solving abilities; ability to work under stress; knowledge of healthcare regulations; and proficiency in community resources. Must collaborate effectively with care teams and families to optimize patient outcomes.