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Registered Nurse Care Coordinator
2 months ago
OverviewThe Registered Nurse Care Coordinator collaborates with interdisciplinary teams and healthcare professionals, both within and outside the organization, to enhance patient care through effective resource utilization and monitoring. This role assumes a leadership position to ensure safe discharge planning while achieving optimal clinical and financial outcomes. The Care Coordinator oversees care and services throughout the acute care episode and across the healthcare continuum.
ResponsibilitiesPatient Assessment
- Conducts face-to-face assessments for all new patients within 24 hours or the next business day to determine the appropriateness for acute care and to anticipate high-level care planning needs. Screens high-risk patients with a LACE score of 10 or higher to minimize 30-day readmissions. Engages with attending physicians regarding potential barriers to care transitions identified during this process.
- Leads the transition process in partnership with the multidisciplinary team and the patient/family, assisting in executing plans and interventions to facilitate the hospital stay and manage length of stay effectively.
- Facilitates patient care conferences and complex case discussions proactively as needs arise to reduce avoidable readmissions.
- Provides Important Message notices and choices to Medicare patients as appropriate.
- Identifies and reports opportunities for process improvement by documenting avoidable days in care per established guidelines.
- Monitors and facilitates the appropriateness of tests, procedures, consultations, treatment plans, and resource utilization.
- Collaborates with social workers for patients with complex clinical, financial, and psychosocial needs.
- Reviews physician orders and patient progress daily, intervening with care coordination as necessary. Works with other departments to eliminate barriers as needed.
- Actively participates in multidisciplinary rounds and meetings that promote comprehensive and coordinated care plans, monitoring progress against established goals.
- Provides clear and timely information regarding the patient's care plan to the next provider.
- Builds trusting relationships with attending physicians, patients, families, and other healthcare team members. Maintains communication with patients, families, physicians, and team members to ensure the most cost-effective care plan is implemented and appropriate in-network providers are utilized.
- Establishes a supportive relationship with patients and their caregivers, encouraging patient engagement and guiding them through the transition phase.
- In accordance with clinical guidelines, develops a comprehensive care transition plan, organizing and integrating necessary resources to meet the goals outlined in the assessment.
- Documents the care plan and updates any changes in the electronic medical record.
- In collaboration with relevant services, arranges home care, durable medical equipment, and post-acute services in partnership with social workers. Maintains strong relationships with community providers.
- Assists with medication-related issues for patients as needed.
- Facilitates legal guardianship, competency determinations, and cases involving potential abuse, ensuring all legal documents are completed. Collaborates with the Corporate Director and Manager of Case Management as required.
- Provides counseling and support as necessary, identifying cases that may benefit from palliative care and initiating consults as needed.
- Acts as a resource for patients, physicians, administration, and other disciplines regarding care management functions and expertise.
- Participates in defining, maintaining, and interpreting care management standards of practice.
- Educates patients and families about community agencies and resources.
- Reinforces the early identification of changes in patient conditions and adjustments in care transition plans.
- Takes responsibility for personal professional growth and shares knowledge with colleagues and other healthcare providers.
- Ensures assigned work is performed safely, adhering to established departmental safety standards and reporting any unsafe conditions promptly.
DCH Standards
- Maintains performance, patient, and employee satisfaction, as well as financial standards as outlined in performance evaluations.
- Complies with requirements as detailed in the Employee Handbook.
- Adheres to DCH Behavioral Standards, fostering positive relationships with patients, families, coworkers, and oneself.
- Utilizes electronic mail, time and attendance software, learning management systems, and intranet as required.
- Complies with all DCH Health System policies and procedures.
- Performs other duties as assigned.
Qualifications
- Registered Nurse with a minimum of 2 years of experience required; BSN or related bachelor's degree in a healthcare field preferred, along with relevant experience in utilization and/or case management.
- Current Alabama RN Licensure.
- Knowledge of managed care, governmental payers, and third-party reimbursement.
- Proficiency in Microsoft Office applications and information systems, including but not limited to MIDAS.
- Demonstrated critical thinking skills and ability to prioritize workload effectively.
- Ability to exercise clinical judgment and make autonomous decisions.
- Strong interpersonal skills for both professional and lay interactions.
- Excellent organizational skills.
- Demonstrated knowledge of performance improvement activities.
- Familiarity with data management and reporting practices.
- Strong communication skills.
For over 90 years, DCH Health System has been a trusted provider of quality and compassionate healthcare to the residents of West Alabama. Based in Tuscaloosa, AL, DCH Health System encompasses DCH Regional Medical Center, Northport Medical Center, and Fayette Medical Center, offering a wide range of services including cancer treatment, critical care, cardiac services, home health care, and much more.
