Senior Care Coordination Nurse
2 weeks ago
Position Overview
The Senior Care Coordination Nurse is tasked with evaluating transitional care requirements, orchestrating care throughout the healthcare continuum, and collaborating with patients and their families to ensure comprehensive care for the most intricate cases during acute hospital stays. This role demands a high level of clinical proficiency to work alongside physicians and healthcare teams, facilitating optimal and efficient treatment strategies to enhance the patient's care journey while hospitalized, as well as preparing for post-discharge support.
Key Responsibilities Include
- Assessing transitional care needs, clinical care progression, psychosocial evaluations, and engaging in patient/family care discussions, interdisciplinary meetings, and educational sessions.
- Effectively collaborates with utilization review nurses, physicians, and interdisciplinary teams to deliver a thorough assessment of the patient's medical and psychosocial requirements, including any social determinants of health, goals, and ongoing care necessities.
- Ensures that patients are on track towards their discharge objectives and actively works to eliminate any barriers.
- Seeks input from relevant disciplines and departments to proactively identify and address delays, expediting care and facilitating timely discharge.
- Participates in the orientation and mentoring of new staff members as needed, guiding them in clinical progression and effective transitional planning.
- May undertake additional responsibilities as assigned.
Assessment: Initiates assessments based on initial screenings to evaluate patients' psychosocial risk factors and resource availability for discharge. Collaborates with financial counselors and utilization management nurses to review insurance and coverage requirements, ensuring compliance. Works closely with patients, families, physicians, and care teams to establish and support care progression and discharge plans. Regularly meets with care teams to ensure timely and effective patient management. 30%
Care Progression: Collaborates with physicians and care teams to facilitate communication regarding patient care progression, ensuring timely and efficient service delivery. Identifies and addresses potential delays in diagnostics or treatments that could hinder discharge. Discusses with physicians the medical necessity for inpatient testing that may be more suitable for outpatient settings. Actively resolves discharge barriers and escalates issues to leadership as necessary. 20%
Disposition Planning: Oversees all aspects of discharge planning for assigned patients, implementing timely and resource-efficient discharge strategies. Engages with patients and families to assess needs and develop tailored discharge plans in partnership with physicians. Identifies and documents barriers to timely discharge and responds to referrals for post-acute needs from physicians and care teams. Participates in interdisciplinary rounds to confirm discharge dates and recommend appropriate care transitions. Ensures consensus on discharge plans among patients, families, physicians, care teams, and payers. Initiates post-acute referrals through departmental processes for smooth transitions to subsequent care levels. Considers cultural and religious beliefs in service delivery and continuity of care. 20%
Documentation: Completes initial clinical and psychosocial assessments, ensuring accurate and timely documentation in medical records. Maintains up-to-date records and clear documentation of interactions with patients, families, physicians, and community partners regarding discharge plans. Tracks avoidable days and reports trends leading to undesired outcomes. 10%
Precepting and Mentoring: Assists leadership in precepting new hires as needed, mentoring less experienced staff in navigating complex patient care situations. Serves as a preceptor and mentor for student interns. 10%
Professional Development: Completes all required competency assessments and mandatory education, supporting departmental goals that contribute to organizational success. 10%
Required Qualifications
Bachelor's Degree in Nursing from an accredited institution is mandatory.
Licenses and Certifications
All certifications must be obtained upon hire unless specified otherwise.
- Registered Nurse (Single State) or RN - Multi-state Compact
- Basic Life Support (BLS) Certification
- Accredited Case Manager or Certified Case Manager Certification
A minimum of 3 years of experience as a staff nurse in an acute care hospital setting is required.
A minimum of 2 years of experience as a case manager in a hospital or payer-based model, demonstrating expertise in case management competencies to guide care teams through complex discussions is essential.
Essential Skills
Strong written and verbal communication skills are essential.
Must exhibit maturity, self-confidence, objectivity, and a positive demeanor.
Self-directed with the ability to perform well under pressure, adapt to change, and thrive in a fast-paced environment.
Proficient assessment, interviewing, organizational, and problem-solving skills are required.
Knowledge of local, state, and federal regulations is necessary.
Familiarity with community and state-wide resources and programs is important.
Ability to collaborate effectively with physicians, care team members, and patients/families throughout the continuum of care.
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