Care Coordinator RN

Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions. Specific functions within this role include: Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in 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. May have other duties assigned Core Responsibilities and Essential Functions: Assessment * Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge. * Partners with the PAS, financial counselor 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. 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. * Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers. * 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. * 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. 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