Care Coordinator RN

As a RN Care Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience. Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions. To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint. - 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. - Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.