Full Time Days + Benefits
Acute Care Coordination
Rock Island, IL
Responsible for the coordination of care and services for the patient through collaboration with the interdisciplinary team. Monitors plan of care to address physical and psychosocial needs and provide problem solving assistance. Coordinates services, transitions of care, discharge planning, referrals to appropriate community agencies and assists with advance directives when appropriate. Provides leadership and promotes communication and collaboration among members of the interdisciplinary team, patients and families to ensure that specific patient outcomes are achieved and variances are evaluated and addressed as needed. Collaborates with members of the interdisciplinary team to achieve department and hospital goals related to coordination of care, reducing readmissions and managing length of stay.
· Facilitates the coordination of discharge planning to assure excellence in patient care and patient flow
· Assess patient’s clinical and psychosocial needs, identifies risk factors and develops plan based on identified needs
· Identifies needed interventions, communicates and collaborates with physicians and primary nurse to individualize plan of care
· Collaborates with patient, family, and other members of the healthcare team to address patient needs related to care coordination and assist with managing length of stay and prevent readmissions
· Coordinates and facilitates interdisciplinary planning and communication through care coordination rounds, complex care meetings, and discharge huddles
· Facilitates meetings with patients, significant others, and providers to ensure participation in the plan of care and discharge planning through ongoing assessments and coordination of care
· Researches and facilitates referrals to appropriate community agencies to assist in the development of a discharge plan individualized to each patient and their family
· Identifies need for POA or advance directives and provides assistance with completion of AD documents
· Adheres to the requirements of CMS, The Joint Commission, and payers related to coordination of care, discharge planning, patient interventions and documentation
· Develops and maintains knowledge of utilization management criteria and communicates with UM Specialist to ensure medical necessity and appropriate patient class for hospital stay and qualifications met for next level of care
· Document all necessary components related to discharge planning in the electronic medical record
· Through appropriate discharge planning, monitor quality assurances such as patient experience, length of stay, and reduction of readmissions
· Collaborates with team members in planning and implementation of strategies to manage length of stay and prevent readmissions
· Maximizes positive financial outcomes for patients and hospital by reviewing medical record and making recommendations as needed to insure appropriate coordination of care, length of stay, discharge planning, and quality of care
· Assists in constructive evaluation of departmental services through participation in the Quality Improvement projects and implementation of systems to increase effective case management by all members of the health care team
Identify items that are minimally required to perform the essential functions of this position.
Preferred or Specialized
Not required to perform the essential functions of the position.
BSN or equivalent advanced degree preferred.
Two years of experience in acute care, intermediate care, or home care (or comparable).
Three to five years clinical experience in an acute care, intermediate care or home care setting preferred
RN license in Iowa and Illinois required. (License in second state must be obtained within 30 days of hire.)
CPR certification upon hire.
Valid driver’s license when driving any vehicle for work-related reasons.
Must have knowledge of the nursing process and management of patient care. Excellent verbal and written communication skills, including the ability to communicate with physicians, hospital staff, patients, families and community agencies required. Ability to problem solve, plan, organize, and facilitate services. Ability to negotiate and establish effective working relationships with members of the interdisciplinary health care team, patients and families required. Ability to identify and act upon psychosocial needs and work independently in outcome oriented environment required. Above average skills with computer and software programs required.
Knowledge of Medicare Conditions of Participation and Joint Commission Standards preferred.
Knowledge of community resources and agencies preferred
Use of usual and customary equipment used to perform essential functions of the position. Comfortable with computer—keyboard and application skills.
Basic knowledge of Excel, Word.
Writes, reads, comprehends and speaks fluent English.