Role: The Care Coordinator RN Sr. is responsible for assessing patient needs, coordinating care across the continuum, and facilitating discharge planning for complex cases during acute hospital admission.
Key Responsibilities:
Conduct comprehensive psychosocial, functional, and medical assessments; collaborate with physicians and care teams to develop and implement individualized care and discharge plans. Manage all aspects of discharge planning, ensuring timely and efficient transitions to post-acute care, while addressing barriers and coordinating with community resources. Participate in interdisciplinary rounds, patient/family education, and care conferences to promote optimal care progression. Document interactions, assessments, and care plans accurately and promptly in medical records. Mentor new staff and interns, supporting professional development and clinical excellence. Identify and resolve delays in care, escalate barriers, and ensure compliance with policies and regulations.
Qualifications & Skills:
Minimum of 3 years of acute care nursing experience, with at least 2 years in care coordination or case management.
Required certifications include BLS and RN licensure.
Must demonstrate excellent communication, organizational, and problem-solving skills, with the ability to work collaboratively in a fast-paced environment. Knowledge of healthcare regulations and community resources is essential.