Senior Care Coordination Registered Nurse

The Senior Care Coordination RN assesses complex patients’ transitional care needs during acute admissions and coordinates care progression and discharge planning. The role partners with patients, families, physicians and interdisciplinary teams to address clinical, psychosocial, insurance and resource needs, resolve delays, support efficient care and mentor new hires. Assess patients’ psychosocial risk factors, functional status and available resources for discharge. Coordinate transitional care planning and support timely progression of care with physicians and interdisciplinary teams. Assess insurance coverage and payer requirements in collaboration with financial counselors, PAS and utilization review staff. Identify barriers or delays in diagnosis, treatment and discharge, and seek appropriate consultations to resolve them. Participate in patient and family care conferences, interdisciplinary rounds and patient education. Orient and mentor new hires in clinical progression, case reviews and discharge planning as needed. Psychosocial assessment Transitional care planning Discharge planning Care progression coordination Clinical case review Utilization review collaboration Insurance and payer requirements assessment Length-of-stay management Interdisciplinary care coordination Patient and family education Registered Nurse (RN) license