As our RN Care Coordinator, you will help patients and their families navigate the healthcare continuum and coordinate individualized care plans so they can achieve optimal health outcomes and experience a seamless transition across care settings.

Every day, you will collaborate with interdisciplinary teams to assess patient needs, coordinate services, and develop comprehensive care plans. You will be expected to advocate for patients, facilitate transitions of care, monitor progress toward goals, and connect patients with appropriate community and healthcare resources.

To be successful in this role, you will demonstrate strong clinical judgment, exceptional communication and collaboration skills, and experience coordinating care across multiple disciplines and settings while maintaining a patient-centered approach.

• Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request, and reassesses the patient as appropriate while updating the plan accordingly.

• Facilitates the development of a multidisciplinary discharge plan, engaging other relevant health team members, the patient and/or patient representative, and post-acute care providers in accordance with the patient's clinical or psychosocial needs, choices, and available resources.

• Collaborates with the healthcare team and post-acute service providers to ensure timely and smooth transitions to the most appropriate type and setting of post-acute services based upon patients' clinical needs.

• Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.

• Responsible for patient education and advocacy.

Required:

• Graduate of an accredited school of nursing
• Minimum of two (2) years of acute hospital clinical experience or a Master's degree in Case Management or Nursing field in lieu of 1 year of experience
• Current California RN license
• Basic Life Support (BLS) certification (American Heart Association) required within 3 months of hiring
• Knowledge, Skills, Abilities, and Training:
  • Knowledge of CMS standards and requirements.
  • Able to apply clinical guidelines to ensure progression of care.
  • Knowledge of managed care and payer environment preferred.
  • Must have critical thinking and problem-solving skills.
  • Collaborate effectively with multiple stakeholders.
  • Professional communication skills.
  • Understand how utilization management and case management programs integrate.
  • Ability to work as a team player and assist other members of the team where needed.
  • Thrive in a fast paced, self-directed environment.
  • Proficient in prioritizing work and delegating where indicated.
  • Highly organized with excellent time management skills

Preferred:

• Bachelor's Degree in Nursing (BSN) or related healthcare field
• At least five (5) years of nursing experience
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification