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Care Coordination Specialist
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The RN Care Coordinator Regional Float is responsible for overseeing the progression of care and discharge planning for identified patients requiring these services. This role is designed to meet the individual's health needs while promoting quality of care, cost-effective outcomes, and adherence to hospital policies, standards of practice, and Federal and State regulations.
Key Responsibilities- Completes and documents a discharge planning assessment on those patients identified by the designated screening process or upon request.
- Reassesses the patient as appropriate and updates the plan accordingly.
- Facilitates the development of a multidisciplinary discharge plan engaging other relevant health team members, the patient, and/or patient representative, and post-acute care providers in accordance with the patient's clinical or psychosocial needs, choices, and available resources.
- Oversees and evaluates the implementation of the discharge plan.
- Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence-based guidelines/criteria.
- Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon the patient's clinical needs.
- Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.
- Responsible for delivery of appropriate patient notifications and related documentation.
- Responsible for patient education and advocacy.
- Participates in performance improvement teams and programs as necessary.
- Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
- Responsible for completing required education within established timeframes.
- Adheres to all hospital policies, standards of practice, and Federal or State regulations pertaining to their practice.
- Performs other duties as assigned, including utilization review as necessary.
- Graduate of an accredited school of nursing.
- Minimum two (2) years of acute hospital clinical experience or a Master's degree in Case Management or Nursing field in lieu of 1 year experience.
- RN license in the state(s) covered is required.
- BLS required within 3 months of hiring if located within hospital.
- Preferred qualifications include a Bachelor's Degree in Nursing (BSN) or related healthcare field, at least five (5) years of nursing experience, Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification, and knowledge of managed care and payer environment.
