Registered Nurse (RN) Care Coordinator

• →Lead discharge planning from admission through post-discharge follow-up. Conduct comprehensive assessments of patients’ clinical, psychosocial, and discharge planning needs. Develop, implement, and update individualized and cost-effective discharge plans. Utilizes sequencing of interventions for safe, timely, efficient, effective, equitable, and patient-centered transitional planning. Coordinate safe and timely transitions to appropriate levels of care including but not limited to home, skilled nursing facility, acute rehab, and behavioral health.
• →Collaborate with the interdisciplinary team, patient, their family/support system, payers, and community resources to ensure a smooth transition of care. Act as a liaison between the clinical team, patient and family, and any external agencies in the development of safe discharge plans. Participate in daily rounds, case conference, family meetings, weekly outlier case reviews, and multidisciplinary team meetings, communicating discharge updates clearly and proactively to all stakeholders.
• →Ensure compliance with federal and state discharge planning regulations, in accordance with CMS’ Conditions of Participation. Monitor length of stay and identify/resolve barriers to timely discharge. Promote transparency and open communication by maintaining accurate, timely, and compliant documentation in the medical record. Maintain current knowledge of care management best practices and regulatory changes and understand Medicare/Medicaid, managed care, and other payer requirements. Delivers all notices (i.e. Important Message from Medicare, Medicare Outpatient Observation Notice) appropriately and according to CMS regulatory guidelines.
• →Promote patient-centered care and shared decision-making in the development of appropriate discharge plans. Educate patients and families on treatment plans, discharge options, and available resources. Places referrals to complex case management as needed.
• →Participate in quality improvement initiatives related to readmissions, throughput, and patient outcomes. Identify and document internal and external avoidable days. Act as a resource to fellow non-clinical care coordinators and assist with appropriate discharge planning as necessary.

• Program Graduate, Nursing - Diploma Program (Required) or
• Associates Degree,  Nursing (Required) or
• Bachelors Degree, Nursing (Preferred)

• 3-4 years Clinical experience required (may include LPN experience) (Required)
• 1 year Case management experience (Preferred)

• Registered Nurse (RN) - Virginia Department of Health Professions (VDHP)   Upon Hire(Required)
•  Accredited Case Manager (ACM) - American Case Management Association (ACMA)/CCM Upon Hire (Preferred)

To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.