Registered Nurse (RN) Care Coordinator

Works under the supervision of the department leadership and is responsible for working in collaboration with the healthcare team to coordinate the care and service to patients across the continuum of care, promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical and resource outcomes. Lead discharge planning from admission through post-discharge follow-up. Conduct comprehensive assessments of patients' clinical, psychosocial, and discharge planning needs.

Develop, implement, and update individualized and cost-effective discharge plans. Coordinate safe and timely transitions to appropriate levels of care including home, skilled nursing facility, acute rehab, and behavioral health. Collaborate with the interdisciplinary team, patient, family/support system, payers, and community resources to ensure smooth transition of care.

Ensure compliance with federal and state discharge planning regulations per CMS Conditions of Participation. Monitor length of stay and identify/resolve barriers to timely discharge. Educate patients and families on treatment plans, discharge options, and available resources.

Participate in quality improvement initiatives related to readmissions, throughput, and patient outcomes. Requires Nursing Diploma or Associates Degree (Required), Bachelors Degree (Preferred). 3-4 years clinical experience required.

RN license from Virginia Department of Health Professions required upon hire. ACM or CCM certification preferred upon hire.