Role Overview: The Complex Care Coordinator assesses and manages the needs of high-risk, complex patients, ensuring safe discharge planning and care continuity. They serve as an expert resource for clinical, psychosocial, and resource-related issues, collaborating with the care team and engaging patients and families to facilitate appropriate transitions across care settings.
Key Responsibilities:
- Conduct comprehensive clinical and psychosocial assessments to develop individualized discharge plans.
- Coordinate care across the continuum, addressing barriers to timely discharge and resource needs.
- Partner with interdisciplinary teams, community resources, and family members to support patient needs, including end-of-life planning.
- Document assessments, interventions, and care plans accurately in electronic health records.
- Mentor and precept new staff and interns, sharing expertise on complex cases and social determinants of health.
- Participate in hospital meetings, facilitate discharge processes, and support community agency negotiations.
- Ensure compliance with policies, regulations, and ongoing professional development.
Qualifications & Skills:
- Associates or Bachelor’s Nursing degree; RN license (single or multi-state compact).
- Minimum 3 years healthcare experience, with at least 2 years in care coordination within a hospital or community setting.
- Certifications: BLS required upon hire.
- Excellent communication, assessment, organizational, and problem-solving skills.
- Knowledge of regulations, community resources, and ability to work collaboratively with diverse teams and patient families.