Care Coordination Registered Nurse
2 weeks ago
Case Management
Daily Work Schedule: 8:30am-5:00pm
Shift:
Daytime
Scheduled Bi-Weekly Hours:
80
Position Overview: Responsible for the proactive management and timely transition of designated patients to the most suitable level of care throughout their healthcare journey. This role significantly influences critical outcomes such as achieving exceptional performance in length of stay, optimizing resource utilization, and minimizing readmissions and unnecessary emergency visits. Collaborates effectively with physicians, nursing staff, and members of the multidisciplinary team (including Home Care and Primary Care Provider offices), as well as various internal and external resources.
Key Responsibilities:
- Conducts comprehensive care coordination assessments within 24 hours of patient admission, including evaluations for readmission and transition planning.
- Partners with social workers and other healthcare professionals to guarantee a safe, appropriate, and timely transition to the next level of care, considering the patient's available resources.
- Evaluates patient and family needs to eliminate barriers and develop effective discharge plans (e.g., addressing length of stay obstacles).
- Identifies unsigned level of care (LOC) orders; communicates with utilization management nurses and secures orders from healthcare providers.
- Reviews current Diagnosis-Related Group (DRG) and length of stay (LOS) data within the electronic health record to assess discharge planning needs and identifies the family member designated as the point of contact.
- Assesses the risk of readmission for specific patient populations and initiates interventions aimed at enhancing the patient's ability to transition successfully along the care continuum.
- Facilitates discharge planning coordination and referrals by making appropriate connections to social services, ancillary departments, outpatient case management, durable medical equipment (DME), post-acute placement, and other external agencies in accordance with Standard Operating Procedures (SOP).
Qualifications:
Required:
- Current state licensure as a Registered Nurse (RN).
- Bachelor's degree in nursing from an accredited institution, or actively pursuing a degree to be completed within five years of accepting the position.
- A minimum of three years of experience in acute hospital care.
Preferred:
- Experience in utilization management, case management, critical care, or quality management related to patient outcomes.
- Certification in Case Management (ACM or CCM).
- Basic Life Support (BLS) certification as a Healthcare Provider from the American Heart Association, American Red Cross, or equivalent through the Military Training Network (MTN).
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