Senior Care Coordination Nurse
2 weeks ago
Position Overview
The Senior Care Coordination Nurse (RN Sr) plays a crucial role in evaluating transitional care requirements, orchestrating care throughout the healthcare continuum, and collaborating with patients and their families to ensure comprehensive care needs are addressed, particularly in complex cases during acute hospital admissions. This position demands advanced clinical knowledge to work alongside physicians and healthcare teams to formulate optimal treatment strategies that enhance the care process during hospitalization and facilitate effective post-discharge planning.
Key Responsibilities Include
- Conducting transitional care assessments, evaluating clinical progress, and assessing psychosocial and functional status while engaging in patient and family care discussions.
- Collaborating efficiently with utilization review nurses, physicians, and interdisciplinary teams to deliver a thorough evaluation of patients' medical and psychosocial needs, as well as any social determinants impacting health.
- Ensuring patients are on track for discharge and addressing any barriers that may arise.
- Consulting with relevant departments to proactively identify and mitigate delays, expediting care and discharge processes.
- Participating in the orientation and mentoring of new staff members, guiding them in clinical assessments and effective discharge planning.
- Additional responsibilities may be assigned as necessary.
Assessment: Initiates comprehensive evaluations based on initial screenings, identifying psychosocial risk factors and resource availability for discharge. Collaborates with financial counselors and utilization management nurses to assess insurance requirements, ensuring compliance with payer guidelines. Works closely with patients, families, and the care team to establish and support care progression and discharge strategies.
Care Progression: Partners with physicians and care teams to enhance communication regarding patient care progression, ensuring timely and effective service delivery. Identifies and addresses potential delays in diagnostics or treatments that could hinder discharge.
Disposition Planning: Oversees all discharge planning aspects for assigned patients, implementing timely and resource-efficient strategies. Engages with patients and families to assess needs and create tailored discharge plans in collaboration with healthcare providers. Documents barriers to timely discharge and participates in interdisciplinary rounds to confirm discharge timelines and recommend optimal care transitions.
Documentation: Completes initial clinical and psychosocial assessments, ensuring all records are current and accurately reflect interactions with patients, families, and care teams. Tracks avoidable delays and reports trends affecting patient outcomes.
Precepting and Mentoring: Assists leadership in training new hires and mentoring less experienced staff in navigating complex patient care situations.
Professional Development: Engages in ongoing professional competency assessments and mandatory education, supporting departmental objectives that contribute to organizational success.
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
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 in case management within a hospital or payer-based model, demonstrating expertise in guiding 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.
Ability to work independently under pressure, adapt to change, and thrive in a fast-paced environment.
Proficient assessment, interviewing, organizational, and problem-solving skills are necessary.
Knowledge of local, state, and federal regulations is required.
Familiarity with community and statewide resources and programs is essential.
Ability to collaborate effectively with physicians, care teams, and patients/families throughout the continuum of care is crucial.
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