Role Overview: The Complex Care Coordinator is responsible for assessing and managing the care needs of high-risk, complex patients during transitions across the healthcare continuum. They serve as an expert resource, collaborating with patients, families, and the care team to develop and implement safe, timely discharge plans that address clinical, psychosocial, and resource needs.
Key Responsibilities:
- Conduct comprehensive clinical and psychosocial assessments to facilitate discharge planning.
- Manage a caseload of complex patients, coordinating care and resources to ensure optimal patient outcomes.
- Participate in interdisciplinary team meetings, providing guidance on community services, social determinants of health, and resource coordination.
- Serve as a specialist on psychosocial issues, end-of-life planning, and resource needs, supporting patient and family decision-making.
- Assist in precepting and mentoring new staff and interns, sharing expertise on complex cases and family dynamics.
- Facilitate hospital team meetings to reduce length of stay and resource utilization.
- Implement discharge plans, identify barriers, and coordinate post-acute referrals, ensuring compliance with eligibility criteria and regulations.
- Document assessments, care plans, and services accurately in the electronic health record.
- Support professional development and contribute to quality improvement initiatives.
Qualifications & Skills:
- Associate’s or Bachelor’s Nursing degree (RN license required, multi-state license preferred).
- Minimum of 3 years healthcare experience, with 2 years in care coordination within acute care settings.
- Current BLS certification.
- Excellent communication, assessment, organizational, and problem-solving skills.
- Knowledge of healthcare regulations, community resources, and social determinants of health.
- Maturity, self-confidence, and ability to work under stress in a fast-paced environment.