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The RN Care Coordinator ED (RNCC-ED) serves as the clinical lead for patient progression, medical discharge readiness, and coordination of routine clinical transition planning, partnering closely with providers, the social work care coordinator (SWCC) and the case management assistant (CMA) to ensure efficient patient progression, medical discharge readiness, and safe transitions of care. The RNCC is responsible for coordinating clinical aspects of discharge planning, leading interdisciplinary collaboration, and driving progression toward discharge milestones.
The RNCC-ED manages routine and clinically focused discharge planning needs, while the SWCC manages complex psychosocial, behavioral, legal, guardianship, homelessness, placement, and high-barrier discharges. The RNCC-ED functions as a key leader in interdisciplinary rounds, supports throughput initiatives, and is cross-trained in Utilization Management (UM) and Clinical Documentation Integrity (CDI), with working knowledge of top Diagnosis-Related Groups (DRGs) impacting organizational performance and reimbursement.
Specific functions within this role include: Care Coordination & Clinical Progression Real-time consultation/collaboration with ED and Admitting provider on patient admission/documentation. Ensure timely completion of initial assessments and progression-of-care documentation. Monitor patient progression toward established clinical and discharge milestones.
Collaborate with providers to address medical, operational, and payer-related barriers to discharge. Lead coordination of clinical discharge planning activities for assigned patients. Ensure appropriate escalation of delays or barriers impacting throughput and length of stay.
Utilization Management & CDI Support Maintain cross-functional knowledge and competency in Utilization Management (UM) and Clinical Documentation Integrity (CDI). Collaborate with UM and CDI teams to support appropriate patient status, medical necessity, and documentation accuracy. Maintain working knowledge of organizational priority DRGs and quality indicators.
Support denial prevention and efficient resource utilization. Interdisciplinary Team Leadership Lead and coordinate interdisciplinary collaboration to ensure efficient patient progression to discharge. Participate in and help facilitate interdisciplinary rounds and daily progression huddles.
Delegate and coordinate work among SW CC and CMA to support efficient patient progression. Serve as a clinical resource for nursing staff, providers, and ancillary departments regarding discharge planning and care coordination processes. Promote accountability for discharge readiness and transition planning activities.
Core Responsibilities and
Complex Disposition Planning * a. Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b. Identifies and documents barriers for timely disposition. c.
Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d. Responds to referrals for patient assistance from RN physicians and the care team. e. 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. f.
Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g. Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h. Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.
Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j. Arranges and facilitates family meetings when needed. k. Allows for any cultural or religious beliefs in providing service and continuity of care.
Assessment * a. Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b. 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. c.
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. 3. Documentation a. Initial psychosocial /functional assessment completed and documented in medical record. b.
Ensure all records are up-to-date and documentation is understandable. c. Ensure timely and accurate documentation of progress notes and interactions with patient/family. d. Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.
Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative *a. Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.
Supports departmental- based goals which contribute to the success of the organization. c. Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes. 4. Precepting/Mentoring a.
Assist leadership with precepting new hires when needed. b. Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c. Serves as a preceptor and/or mentor for student interns Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum
Bachelors Nursing or Associates Nursing or Diploma (Nurse) Nursing Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact Additional License(s) and Certification(s): Required Minimum
Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and Minimum 2 years in care coordination in the acute care setting. Required Required Minimum
Excellent written and verbal communication skill. Must possess maturity, self-confidence, objectivity, and positive attitude. Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required. Knowledge of community and state-wide resources and programs. Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.
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