RN Hospital Care Coordination
Core
Provides clinical coordination services including assessment, planning, and intervention for medically complex patients to facilitate clinical transition planning from the hospital.
Role type
Registered Nurse (RN) Hospital Care Coordinator / Case Manager
Builds
Seamless post-discharge care and services for complex patients
Domain
Healthcare / Hospital Care Management
Required skills
Clinical assessment, care planning, discharge planning, interdisciplinary collaboration, regulatory compliance, resource management, readmission prevention, utilization review
Preferred skills
Palliative care knowledge, advanced care planning, community resource coordination, financial/social needs assessment
Technologies
Predictive tools, care management software, referral systems
Responsibilities
Completes clinical assessments and participates in patient care rounds; Ensures timely progression of care and eliminates barriers; Collaborates with healthcare team to plan anticipated transfer or discharge; Conducts screening or assessment tests to select patients and communicates need for follow-up; Participates in care system processes to prevent potentially preventable readmissions; Supports level of care activities including use of established inpatient guidelines; Provides information and assistance for identified financial or social needs.
Seniority
Mid-level, hands-on IC