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JOB SUMMARY / PURPOSE

The Care Coordinator RN is responsible for overseeing the progression of care and discharge planning for identified patients requiring these services. The Care Coordinator RN performs this role to meet the individual’s health needs while promoting quality of care, cost effective outcomes and by following hospital policies, standards of practice and Federal and State regulations. 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 Care Coordinator RN 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 Care Coordinator RN strives to enhance the patient experience.

ESSENTIAL KEY JOB RESPONSIBILITIES

1. 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.
2. 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.
3. Oversees and evaluates the implementation of the discharge plan.
4. Collaborates with the multidisciplinary team to ensure progression of care and appropriate utilization of inpatient resources using established evidence based guidelines/criteria.
5. 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.
6. Identifies risk for readmission and implements interventions to mitigate those risks for at least a 30-day period.
7. Responsible for delivery of appropriate patient notifications and related documentation
8. Responsible for patient education and advocacy.
9. Participates in performance improvement teams and programs as necessary.
10. Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
11. Responsible for completing required education within established timeframes.
12. Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
13. Performs other duties as assigned, including utilization review as necessary.

Education and Experience

Required

• Graduate of an accredited school of nursing.
• 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.

Preferred

• Bachelor’s Degree in Nursing (BSN) or related healthcare field.
• At least five (5) years of nursing experience.

Licensure and Certifications:

Required

• Current licensure as a Registered Nurse in the state of Washington (RN-WA).
• BLS required within 3 months of hiring if located within hospital

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.

Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.

Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.

We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.