Role: RN Complex Care Coordinator responsible for assessing and managing care transitions for complex patients, ensuring safe discharges, and coordinating across healthcare continuum.
Key Responsibilities:
- Conduct comprehensive clinical and psychosocial assessments for high-risk patients.
- Develop and implement individualized discharge plans in collaboration with patients, families, and care teams.
- Coordinate post-acute care referrals and facilitate smooth transitions to appropriate care settings.
- Serve as a resource for complex psychosocial, resource, and end-of-life care needs.
- Partner with interdisciplinary teams, community agencies, and support services to address social determinants of health.
- Mentor and precept new staff and interns, sharing expertise on complex cases.
- Document assessments, interventions, and care plans accurately and timely in electronic health records.
- Support quality improvement initiatives and adhere to organizational policies and standards.
Qualifications & Skills:
- Minimum 3 years healthcare experience in acute care or related settings, with at least 2 years in care coordination.
- Associates or Bachelor’s Nursing degree; RN licensure required (multi-state compact preferred).
- Current BLS certification.
- Excellent communication, assessment, organizational, and problem-solving skills.
- Knowledge of regulations, community resources, and care coordination best practices.
- Ability to work collaboratively, handle stressful situations, and adapt in a fast-paced environment.