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The RN Clinical Educator - Care Coordination Specialist will play a vital role in overseeing the progression of care and discharge planning for identified patients requiring these services. This position will be responsible for promoting quality of care, cost-effective outcomes, and adherence to hospital policies, standards of practice, and Federal and State regulations.
Key Responsibilities- Discharge Planning: Completes and documents a discharge planning assessment on those patients identified by the designated screening process or upon request.
- Facilitating Discharge Plans: 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.
- Overseeing Discharge Plan Implementation: Oversees and evaluates the implementation of the discharge plan.
- Collaboration with Healthcare Team: Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence-based guidelines/criteria.
- Transition Coordination: 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.
- Readmission Risk Mitigation: Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.
- Patient Notifications and Documentation: Responsible for delivery of appropriate patient notifications and related documentation.
- Patient Education and Advocacy: Responsible for patient education and advocacy.
- Performance Improvement: Participates in performance improvement teams and programs as necessary.
- Organizational Alignment: Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
- Education and Compliance: Responsible for completing required education within established timeframes and adheres to all hospital policies, standards of practice, and Federal or State regulations pertaining to their practice.
- Education: Graduate of an accredited school of nursing.
- Experience: 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.
- Licensure: RN license in the state(s) covered is required.
- Certifications: BLS required within 3 months of hiring if located within the hospital.