Facility: Spalding Medical Center

Job Summary:

The Care Coordinator RN Sr. (RN Sr) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met the most complex cases during the patient's acute admission. The RN Sr requires strong clinical expertise to partner with physicians and care teams to drive optimal and efficient treatment plans to streamline progression of care while in the hospital, as well as, planning for post discharge care. The RN Sr will serve as an expert resource and consultant to the other team members in regards to care progression and assisting in planning to effectively meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions.
Specific functions within this role include:
• Transitional care planning, clinical care progression, psychosocial and functional status assessment, attending patient/family care conferences, interdisciplinary rounds, and patient/family education
• Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs
• Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers
• Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.
• Will participate in orientation and precepting of new employee hires (as needed). The RN Sr will mentor new hires in clinical progression/case reviews and efficient transitional/discharge planning.
• May have other duties assigned.


Core Responsibilities and Essential Functions:

Assessment Based on preliminary screening of patients, initiates assessment of patient’s psychosocial risk factors and availability of resources to assist upon discharge. Partners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patient’s care progression and discharge plans. Meets with physicians and care team routinely to collaborate on timely and efficient patient management. 30%

Care Progression Collaborates with physicians and care team to facilitate communication regarding patient’s care progression to ensure timely and efficient delivery of care. Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays. Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting. Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution 20%

Disposition Planning Manages all aspects of discharge planning for assigned patients. Implements discharge planning timely and provides resources in an efficient manner. Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians. Identifies and documents barriers for timely disposition. Responds to referrals for patient’s post-acute needs from physicians and the care team. Participates in Interdisciplinary Rounds with the patient’s care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers. Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. Refer appropriate cases for social work intervention based on departmental protocol. Allows for any cultural or religious beliefs in providing service and continuity of care. 20%

Documentation Initial clinical/psychosocial assessment completed and documented in medical record. Ensure all records are up-to-date and documentation is clear and concise. Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patient’s discharge plan. Accounts for and indicates all services arranged/delivered in electronic medical record. Track avoidable days and report trends that lead to undesired outcomes. 10%

Precepting/Mentoring Assist leadership with precepting new hires when needed. Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. Serves as a preceptor and/or mentor for student interns 10%

Professional Development and Initiative Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. Supports department-based goals which contribute to the success of the organization. 10%

Required Minimum Education:

Bachelor's Degree in Nursing from an accredited school of nursing required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse (Single State) or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager or Certified Case Manager

Additional License(s) and Certification(s):



Required Minimum Experience:

Minimum 3 years experience as a staff nurse in an acute care hospital setting required.
Minimum 2 years experience as a case manager in a hospital setting or payer-based model with expertise in case management competencies and to guide the care team through complex discussions required.

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment.
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.