Job Description:OverviewThe RN Care Coordinator facilitates and supports care progression optimization and utilization across the organization bydemonstrating active communication, promoting interdisciplinary collaboration and problem solving clinical care andtreatment. The RN CC plans and prioritizes care for individuals and population of patients, focusing on strategies that willpromote optimal health. Demonstrates expertise, current knowledge in nursing care and management of a caseload ofpatients with varying complexities and seeks to improve patient, family and health system outcomes through theapplication of education concepts/skills and preventive care.
Responsibilities

Develops plan of care and makes recommendations to attending’s, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
Solicits recommendations and plan from ancillary therapies; recommends consults as appropriate.
Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
Assumes an active role with providers to progress test results, clinical decision making and next level of care decisions.
Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies and/or makes appropriate referrals.
Identifies readmission risk and contributing factors and works with patient/providers to overcome barriers.
Assists with determination when care conference is appropriate; coordinates scheduling with team & caregivers.
Performs Initial screens to identify who has discharge planning needs and facilitates referrals based on patient choice.
Documents patient data, plan, interventions and outcomes according to department guidelines.
Anticipates and identifies barriers to care progression and need for escalation.