RN Care Coordinator

Dignity Health Mercy San Juan Medical Center is a 370-bed not-for-profit Level 2 Trauma Center located in Carmichael California serving the areas of north Sacramento County and south Placer County for more than 50 years. It is one of the area’s largest and most comprehensive medical centers. Dedicated to the community’s well-being our staff and volunteers provide excellence in care for our patients each year. Mercy San Juan Medical Center has received recognition for being a Comprehensive Stroke Center and Center of Excellence for Bariatric Surgery along with Certificates of Excellence in Perinatal Care Hip- and Knee- Replacement.  

One Community. One Mission. One California

The RN Care Coordinator is responsible for overseeing the progression of care and discharge planning for identified patients requiring these services. The position’s emphasis will be on care coordination communication and collaboration with utilization management nursing physicians ancillary departments insurers and post acute service providers to progress the care toward optimal outcomes at the appropriate level of care. The RN Care Coordinator advocates for the patient and family by identifying valuing and addressing patient choice spiritual needs cultural language and socioeconomic barriers to care transitions. In addition the RN Care Coordinator strives to enhance the patient experience.

Responsibilities: 

• 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.

• 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.

• Oversees and evaluates the implementation of the discharge plan.

• Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.

• 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 delivery of appropriate patient notifications and related documentation

• Responsible for patient education and advocacy.

• Participates in performance improvement teams and programs as necessary.

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Minimum:

• 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.

• Current CA RN licensure

• AHA BLS required within 3 months of hiring if located within hospital

Preferred: 

• At least five (5) years of nursing experience.

• Certified Case Manager (CCM) Accredited Case Manager (ACM-RN) or UM Certification 

• Bachelor's Degree in Nursing (BSN) or related healthcare field

Knowledge Skills and Abilities for success in the role: 

• Able to apply clinical guidelines to ensure progression of care

• Understanding how utilization management and case management programs integrate

• Knowledge of CMS standards and requirements

• Knowledge of managed care and payer environment preferred
• Collaborate/Communicate effectively with multiple stakeholders

• Critical thinking and problem-solving skills

• Thrive in a fast paced self-directed environment.

• Highly organized with excellent time management skills.

• Proficient in prioritizing work and delegating where indicated.

• Ability to work as a team player and assist other members of the team where needed