Care Coordination Nurse

Every day you will meticulously conduct and update discharge planning assessments, facilitating multidisciplinary collaboration for timely and smooth transitions to post-acute care settings. You'll oversee implementation of discharge plans, optimize inpatient resource utilization, identify and mitigate readmission risks, and provide essential patient education and advocacy, all while adhering to hospital policies and promoting cost-effective, quality outcomes. To be successful in this role, you will demonstrate exceptional critical thinking, problem-solving, and professional communication skills.

Your ability to thrive in a fast-paced, self-directed environment, prioritize effectively, and collaborate seamlessly within the Care Coordination Team is crucial. You must be dedicated to furthering the hospital's mission by enhancing the patient experience and ensuring optimal outcomes. This role is scheduled to commence in January 2027. We are accepting applications early to ensure we find the right fit for this role.

Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly. 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 patients clinical or psychosocial needs, choices and available resources.

Oversees and evaluates the implementation of the discharge plan. Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria. 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 patients clinical needs.