What are the responsibilities and job description for the Registered Nurse - Acute Care - Care Coordination - Full Time Days position at Preferred Home Health Care & Nursing Services?
Role Overview: The RN Complex Care Coordinator assesses and manages the needs of complex, high-risk patients in the acute care setting, coordinating care transitions and discharge planning. They serve as a clinical and psychosocial resource, collaborating with patients, families, and the care team to develop safe, timely discharge plans that address medical, social, and resource needs.
Key Responsibilities
Key Responsibilities
- Conduct comprehensive clinical and psychosocial assessments for complex patients.
- Coordinate discharge planning, including resource identification and barrier resolution.
- Partner with interdisciplinary teams to facilitate timely transitions to appropriate care levels.
- Provide guidance on community resources, social determinants of health, and end-of-life care planning.
- Mentor and precept new care coordinators and interns, sharing expertise on complex cases.
- Document assessments, care plans, and progress accurately in electronic health records.
- Support quality improvement and protocol development to optimize patient outcomes.
- Minimum of 3 years in healthcare, with at least 2 years in care coordination in an acute care setting.
- Strong clinical, social, and resource management expertise.
- Excellent communication, assessment, and interdisciplinary collaboration skills.
- Ability to navigate community resources and address complex psychosocial issues.
- Experience in mentoring, precepting, and participating in performance improvement initiatives.