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Senior Care Coordination Nurse
2 months ago
Job Overview
The Senior Care Coordination Nurse (RN Sr) plays a pivotal role in evaluating transitional care requirements, orchestrating care throughout the healthcare continuum, and collaborating with patients and their families to ensure that care needs are effectively addressed during complex acute admissions. This position demands advanced clinical knowledge to work alongside physicians and care teams, facilitating optimal treatment strategies that enhance the efficiency of care while in the hospital and preparing for post-discharge needs. The RN Sr acts as a vital resource and advisor to team members regarding care progression and assists in strategizing to meet patient needs, manage length of stay, and promote resource utilization.
Key Responsibilities Include
- Developing transitional care plans, assessing clinical care progression, evaluating psychosocial and functional status, participating in patient/family care discussions, interdisciplinary rounds, and providing education to patients and families.
- Collaborating effectively with utilization review nurses, physicians, and interdisciplinary teams to conduct comprehensive assessments of patients' medical and psychosocial needs, including social determinants of health, and ensuring continuity of care.
- Monitoring patient progress towards discharge goals and identifying barriers to discharge.
- Consulting with relevant disciplines/departments to proactively address and resolve delays in care, facilitating timely discharge.
- Engaging in the orientation and mentorship of new staff members as needed, guiding them in clinical progression and effective transitional planning.
- Additional responsibilities may be assigned.
Assessment: Initiates assessments based on initial screenings to identify psychosocial risk factors and resource availability for discharge. Collaborates with financial counselors and utilization management nurses to evaluate insurance and coverage requirements, ensuring compliance. Works closely with patients, families, physicians, and care teams to establish and support care progression and discharge plans. Engages in regular meetings with physicians and care teams to ensure timely patient management. 30%
Care Progression: Partners with physicians and care teams to facilitate communication regarding patient care progression, ensuring timely and efficient service delivery. Identifies and addresses delays or obstacles in diagnostics or treatments that may affect discharge timelines. Discusses with physicians the necessity of inpatient testing that could be conducted in outpatient settings. Actively resolves discharge barriers and escalates issues to appropriate leaders for swift resolution. 20%
Disposition Planning: Oversees all aspects of discharge planning for assigned patients, implementing plans efficiently and providing necessary resources. Collaborates with patients and families to assess needs and develop tailored discharge plans in partnership with physicians. Identifies and documents barriers to timely discharge. Participates in interdisciplinary rounds to confirm discharge dates and recommend optimal 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/Mentoring: Assists leadership in precepting new hires as needed. Mentors less experienced staff in navigating challenging situations while supporting patients and families through the continuum of care. Serves as a preceptor and/or mentor for student interns. 10%
Professional Development: Completes all required professional competency assessments and ongoing education. Supports departmental goals that contribute to the organization's success. 10%
Required Qualifications
Bachelor's Degree in Nursing from an accredited institution is required.
Licenses and Certifications
All certifications must be obtained upon hire unless otherwise specified.
- Registered Nurse (Single State) or RN - Multi-state Compact
- Basic Life Support (BLS) - Instructor
- Accredited Case Manager or Certified Case Manager
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 required.
Essential Skills
Exceptional written and verbal communication skills.
Demonstrates maturity, self-confidence, objectivity, and a positive demeanor.
Self-motivated with the ability to perform well under pressure, adapt to change, and thrive in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving abilities.
Knowledge of local, state, and federal regulations is required.
Familiarity with community and state-wide resources and programs.
Ability to collaborate effectively with physicians, care team members, and patients/families throughout the continuum of care.
