RN Care Coordination

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Job Description:

Provides clinical coordination services including assessment, planning and intervention. Patients are identified through predictive tools and referrals from providers, staff or community caregivers to facilitate clinical transition planning for medically complex patients from the hospital when medically indicated. May provide initial and concurrent level of care review and insurance authorization activities.

Principle Responsibilities

• Supports the progression of care for complex patients.
  • Completes clinical assessments and participates in patient care rounds to ensure critical interventions and procedures are completed to achieve optimal patient outcomes.
  • Ensures timely progression of care with proactive identification and elimination of potential delays/barriers in patient care. Escalates barriers to leaderships for resolution.
  • Collaborates with healthcare team, community care providers, patients and families to ensure effective clinical and timely transition of care.
  • Provides information and supports activities related to palliative care and advanced care planning to patients and families experience chronic disease progression.
  • Provides age appropriate patient care based on population served.
• Coordinates appropriate clinical transition of patients in the hospital and Emergency Department.
  • Collaborates with interdisciplinary team to plan anticipated transfer or discharge.
  • Serves as subject matter expert with high knowledge base of integrated, seamless post-discharge care and services offered by the system.
  • Assess clinical stability for discharge and oversee clinical details of transitions.
  • Ensures accurate and complete discharge orders.
  • Identifies patients and families with complex discharge issues, rehab services for functional issues to prepare patients for internal or external transitions.
  • Conducts screening or assessment tests to select patients and communicates the need for follow up with community resources in collaboration with provider.
• Participates in care system process that prevent potentially preventable readmissions.
  • Plan and participate in transition conferences with patients and families.
  • Utilize tools and technology to identify and intervene with patients who are at risk for readmission.
  • Ensure that a complete clinical handoff occurs for at risk patient, which may include referrals.
• Collaborates with health care team to promote appropriate length of stay.
  • Utilizes tools and technology to support appropriate length of stay management.
  • Facilitates timely referrals and transfers of information.
  • Ensures outpatient complex clinical care services are in place at the time of discharge along with other complex clinical care needs.
• Demonstrates appropriate clinical resource management and adherence to commercial and regulatory requirements.
  • Supports level of care activities including use of established inpatient guidelines and internal and external utilization criteria.
  • Collaborates with Social Workers to identify trends or concerns related to reimbursement and discharge planning.
  • Ensures timely interventions for patients who are admitted under observation status.
  • Provides information and assistance for identified financial or social needs.
  • Maintains knowledge of government and private payer networks and services.
  • Collaborates with community and health care resources based on need to coordinate care for the patient.
• Other duties as assigned.

Required Qualifications

• Bachelor's degree in nursing
• 2 to 5 years of nursing experience, with having practiced the equivalent of 2 years in an acute care setting

Licenses/Certifications

• Licensed Registered Nurse - MN Board of Nursing required or
• Licensed Registered Nurse - WI Dept of Safety & Professional Services required
• Case/Care Management Certification within 2 years of hire required. Any current employee will need to complete certifications requirements by 12-31-2024 or at the earliest date when certification work experience requirements have been met

Physical Demands

• Light Work:
• Lifting weight Up to 20 lbs. occasionally, Up to 10 lbs. frequently