Overview Care Coordinator RN (CC RN) at Wellstar. The CC RN 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 role plans effectively to meet the patient\'s needs, manages length of stay, and promotes efficient utilization of resources. It integrates care facilitation, care progression, and transitional care planning functions.
Responsibilities 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 with the utilization review nurse, patient\'s physicians, and interdisciplinary care team to assess medical, psychosocial, social determinants of health needs, goals/outcome attainment, and continued care needs.
Ensure patient progression toward discharge and assist in alleviating barriers.
Seek consultation from appropriate disciplines to proactively identify and resolve delays to expedite care and facilitate discharge.
May have other duties assigned.
Core responsibilities and Essential Functions Assessment: Initiate assessment of chronic disease management needs and psychosocial risk factors; partner with PAS, financial counselor and/or UM nurse to assess insurance requirements; collaborate with patient/family and care team to establish care progression and discharge plans; meet with physicians and care team to coordinate timely patient management.
Disposition Planning: Manage all aspects of discharge planning; implement discharge planning timely; develop individualized discharge plans with patient/family and physicians; identify and document barriers; maintain discharge plan consensus with patient/family, physicians, care teams, and payers; respond to referrals for post-acute needs; participate in Interdisciplinary Rounds to confirm discharge date and level of care; initiate post-acute referrals; refer cases for social work per protocol; respect cultural/religious considerations.
Care Progression: Facilitate communication about care progression; identify delays in diagnostic or treatment steps; discuss medical necessity for inpatient vs outpatient testing; work to resolve discharge barriers and escalate as needed.
Documentation: Complete and maintain initial clinical/psychosocial assessments; keep records up-to-date; document interactions with patient/family, physicians, care team, and community partners; ensure services are recorded in EMR; track avoidable days and trends.
Professional Development: Complete required education and competency assessments; support department goals; serve as a preceptor/mentor when appropriate.
Requirements Required Minimum Education: Associate\'s Degree in Nursing from an accredited nursing program with a Georgia RN license.
Required Minimum Licenses/Certifications: RN (single state) or RN-Compact; BLS or BLS-Instructor; All certifications required upon hire unless stated otherwise.
Required Minimum Experience: Minimum 1 year nursing experience in the acute care setting.
Required Minimum Skills: Excellent written and verbal communication; maturity, self-confidence, objectivity, positive attitude; self-directed and able to work under stress in a fast-paced environment; strong assessment, interview, organizational, and problem-solving skills; knowledge of local/state/federal regulations; knowledge of community resources; ability to collaborate with physicians, care team, and patient/family to advance progression of care.
Location and Employment Type Location: Griffin, GA (May include surrounding areas). Employment type: Full-time.
Note: This description consolidates the role information from the original listing and preserves the essential duties, qualifications, and expectations.