AHD RN Care Coordinator

SUMMARY: The AHD RN Care Coordinator Is responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients; completes initial assessments and develops discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, and identifies cost-effective protocols; follows regulatory compliance guidelines and serves as an active member of the multidisciplinary team and collaborates with the Utilization Management team to manage effective patient throughput.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.

2. Confirm all applicable department and regulatory targets for department performance process improvements are attained (e.g., readmissions, throughput, LOS).


3. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social work, and other healthcare providers and agencies. Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record. Processes referrals and authorizations that adhere to federal, state and local insurance regulatory agencies and offer patient choice per regulation.

4. Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources. In coordination with patient and family wishes, guide/assist in securing needed post discharge services.


5. Identifies potential problems prevents and or resolves barriers to the discharge plan. Along with the social work team member. makes independent assessments and recommendations regarding course of action in complex situations.

6. Mobilize resources to effect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.


7. Ensures continuity of care through effective communication in rounds and written documentation in the EHR, transfer coordination, and discharge planning

8. Collaborates with the UR Specialist and communicates to the attending physician, when cases do not meet level of care criteria, in addition to documenting treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards.


9. Reassesses the patient's condition when changes occur and revises the care plan when appropriate to ensure effective resource utilization and appropriate level of care.

10. Identifies and documents barriers (Avoidable Days) in the EHR

MINIMUM QUALIFICATIONS:

Required Education: Bachelor in Nursing

Preferred Education: Master's in Nursing

Required Experience: Three years of acute care nursing

Preferred Experience: Within the last 3 years, experience in Case Management in an acute care setting or within a medical group or health plan

Required Licenses/Certifications: Active licensure as a Registered Nurse in the state of California, active BLS - Basic Life Support certification issued by the American Heart Association; other advanced life support certifications may be required per unit/department specialty according to patient care policies; CPI - Crisis Prevention Intervention training (required for all positions at John George Psychiatric Pavilion; and certain positions in the Emergency Department.


Preferred Licenses/Certifications: Certification in Case Management, CCM or ACM. Bilingual preferred

Pay Range $61.68 - $102.81
The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate's experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.