RN Care Coordinator

1. Completes and documents a discharge planning assessment on those patients identified by the designated screening process, or upon request. Reassess the patient as appropriate and update the plan accordingly.
2. 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 patients clinical or psychosocial needs, choices and available resources. 
3. Oversees and evaluates the implementation of the discharge plan.
4. Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
5. 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. 
6. Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.
7. Responsible for delivery of appropriate patient notifications and related documentation
8. Responsible for patient education and advocacy.

• Graduate of an accredited school of nursing.
• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• 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.

At CHI Health Creighton University Medical Center - Bergan Mercy, our focus is patient-centered care. Our level I trauma center and academic medical center campus is designed to heal the body, mind, and spirit of every person in a more comfortable, less stressful hospital environment. Our full range of medical services includes trauma services, heart and vascular care, emergency services, surgery, maternity, cancer care, and diagnostic imaging.