Job Summary / Purpose

The RN Care Coordinator is responsible for overseeing the progression of care and discharge planning for identified patients requiring these services. The RN Care Coordinator performs this role to meet the individual's health needs while promoting quality of care, cost effective outcomes and by following hospital policies, standards of practice and Federal and State regulations. The position’s emphasis will be on care coordination, communication and collaboration with utilization management, nursing, physicians, ancillary departments, insurers and post-acute service providers to progress the care toward optimal outcomes at the appropriate level of care. The RN Care Coordinator advocates for the patient and family by identifying, valuing, and addressing patient choice, spiritual needs, cultural, language and socioeconomic barriers to care transitions. In addition, the RN Care Coordinator strives to enhance the patient experience.

Essential Key Job Responsibilities

1. 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.


2. 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.


3. Oversees and evaluates the implementation of the discharge plan.


4. Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.


5. 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.


6. Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.


7. Responsible for delivery of appropriate patient notifications and related documentation


8. Responsible for patient education and advocacy.


9. Participates in performance improvement teams and programs as necessary.


10. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.


11. Responsible for completing required education within established timeframes.


12. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.


13. Performs other duties as assigned, including utilization review as necessary.

Minimum Qualifications