Care Coordination RN Sr. PRN

Job Summary

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

Various (United States of America)

Core Responsibilities and Essential Functions:

Assessment

Based on preliminary screening of patients, initiates assessment of patients 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 patients care progression and discharge plans. Meets with physicians and care team routinely to collaborate on timely and efficient patient management.

Care Progression

Collaborates with physicians and care team to facilitate communication regarding patients 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.

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 patients post-acute needs from physicians and the care team. Participates in Interdisciplinary Rounds with the patients 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.

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 patients 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.

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.

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. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelors Nursing

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

Certified Case Manager-Preferred or Accredited Case Manager-Preferred

Additional License(s) and Certification(s):

ACM or CCM Preferred

Required Minimum Experience:

Minimum 3 years experience as a staff nurse in an acute care hospital setting. Required and 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 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.

Join us and discover the support to do more meaningful workand enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.