Patient Care Coordinator

5 hours ago


Nashville, Tennessee, United States Vanderbilt University Medical Center Full time
Job Summary

As a Patient Care Coordinator for GI Oncology, you will play a vital role in developing and meeting key Pillar outcomes and system improvement goals. You will assist in improving outcomes by reducing all-cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process.

Key Responsibilities
  • Coordinate the evaluation process of the defined patient population, collaborating with other team members to ensure completion of all required information.
  • Support patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
  • Interact routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
  • Develop and manage the processes related to pre-admission and post-discharge care transitions, establishing relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
  • Assist in the development and dissemination of patient education materials/information, including creation of customized medication grids with input from the pharmacist/team as needed.
  • Assist with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities, etc. Coordinate handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
  • Demonstrate reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence.
Technical Capabilities
  • Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research, demonstrating expertise in applying evidence-based practices to challenging and complex situations.
  • RN Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature, possessing mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum.
  • Nursing Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations, conducting primary care patient interviews and physical examination, often taking a lead role in complex patient care situations.
  • Trend Analysis (Intermediate): Demonstrates mastery of trend analyses, recognizing the impact and taking into consideration the effect of seasonality and randomness, having analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods.
Our Nursing Philosophy

We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center's mission of quality in patient care, education, and research. We believe nursing is an applied art and science focused on helping people, families, and communities reach excellent health and well-being.

As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing.



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