Care Coordinator Complex (RN) - Case Manager

Care Coordinator Complex (RN) - Case Manager

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence, and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry and in people's lives.

Job Description

• The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patients and families to assure care needs are met.
• Serves as an expert resource for complex patients and situations and consults with other care team members regarding patients' clinical, psychosocial, and resource needs.
• In conjunction with the patient and physician, assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care.
• Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
• Carries an appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
• Participates in the interdisciplinary team providing information about community-based service offerings (e.g., indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
• Serves as a specialist on issues related to complex psychosocial and discharge needs, end-of-life care planning, resource needs, etc. Provides resource information necessary to aid patients/families in decision-making up to and including support for end-of-life.
• Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
• Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentors other care coordinators in case reviews and discussion of difficult situations.
• May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient populations.
• Supports leaders in negotiating agreements with community agencies and facilities.
• May have other duties assigned as it relates to the hospital complex patient population.

Requirements

• Bachelor's Degree in Social Work or a Master's Degree in Social Work from an accredited college or university required or Bachelor's Degree in Nursing required.
• Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination required.
• Minimum 2 years in care coordination in the acute care setting required.
• Reg Nurse - Board Cert or RN - Multi-state Compact required.
• Basic Life Support or BLS - Instructor required.
• Accredited Case Manager - Preferred or Certified Case Manager - Preferred.

Skills

• Excellent written and verbal communication skills.
• Must possess maturity, self-confidence, objectivity, and a 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.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.