The RN Care Coordinator functions as a part of a multidisciplinary team, including physicians, social workers, discharge planning assistants and payers. This position ensures that patient’s progress in the acute episode of care through post discharge is quality driven while being efficient, cost effective and safe. This position will also be patient focused and outcome oriented.
Licensure, Certification, or Registration Requirements for Hire:
Licensed Registered Nurse in the State of Virginia or eligible
Licensure, Certification, or Registration Requirements for continued employment:
Current RN licensure in Virginia Complete 15 Continuing Education Units per year
Experience REQUIRED: Minimum of three (3) years of nursing experience in an acute care setting
Academic healthcare experience One (1) year of UM/Care Coordination experience Clinical experience with specialty patient population
Baccalaureate Degree in Nursing from an accredited School of Nursing
Master's Degree in Nursing or a healthcare related field from an accredited program
Independent action(s) required:
Works with the attending and consulting physicians to facilitate effective and efficient transition through the process of hospitalization.
Works collaboratively with all members of the multi-disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted, and that resources are efficiently and effectively utilized.
Seeks the expertise of social workers to resolve psychosocial patient care issues and to develop complex patient transition/discharge
plans as needed. Interacts with patients, family members, healthcare professionals, community and state agencies in this effort. Serves as an advanced clinical resource to the team.
Serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information.
The role is responsible for maintaining hospital compliance with the Quality Improvement Organization (QIO) series and CMS guidelines.
Utilizes medical necessity criteria as a tool to assess appropriateness of level and setting of care, assists in the denial and appeals process, assesses quality and identifies and reports potential risk management issues.
Responsible for participation in and completion of all patient safety initiatives appropriate to the position.
The incumbent conducts all job responsibilities according to VCUHS’ Mission and Values.
Responsible for establishing and maintaining a professional rapport with providers, patients/families, and internal customers.
Supervisory responsibilities (if applicable): N/A
Additional position requirements:
Day and Evening shifts available
Age Specific groups served: All
Physical Requirements (includes use of assistance devices as appropriate):
Physical: Lifting 20-50 lbs.
Activities: Prolonged sitting, Walking (distance)
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent, change
Position: Hospital at Home Enrollment RN Care Coordinator – VCU Health at Home
Shift: Weekend Days/Evenings
VCU Health is seeking authentic, passionate and inspiring candidates to staff a new, virtually-enabled Hospital-at Home program, housed in the health system’s Continuum Integration Center in north Richmond. This exciting opportunity offers innovation and professional growth and you would be joining an already incredible team, which is expanding to provide this new service offering under the highly-regarded VCU Health at Home brand.
Hospital-at-Home programs are gaining momentum nationwide, because of the benefits for patients and health systems, including increased patient satisfaction, improved patient outcomes, better performance on value-based metrics and relieving facility capacity constraints. The model operates with a patient-centric focus and a comprehensive, team-based, outcomes-motivated approach to care using population health principles to keep patients healthy.
The focus of the position is:
- To assist the VCU Health at Home clinical team in ensuring quality coordination of care for patients enrolling in to the Hospital at Home program.
- To ensure quality patient care across the continuum, reduce avoidable readmissions, and improve outcomes for both acute inpatients and the highest risk discharged individuals from VCU Health System.
- To use clinical judgement to screen patients for referral eligibility for Hospital at Home.
- To support program growth by advocating for and marketing the Hospital at Home program to both VCU Health clinical team members and patients and their caregivers or families.
- To ensure safe quality enrollment in to the Hospital at Home program by completing clinical and social screening through both chart review and bedside assessment.
- To ensure safe quality transition in to the Hospital at Home program by setting up appropriate home services for the Hospital at Home stay including but not limited to medication delivery, transportation, food services, therapy services, visiting team admission assessment, mobile imaging, social work, and medical equipment/supplies.
- To ensure initial medical and nursing care is set up for individuals enrolled in the Hospital at Home program by managing multiple schedules for both virtual and in-person home visits.
- To initiate quality discharge planning by evaluating for appropriate discharge needs and/or post-acute services such as home health, medical equipment, or medication assistance and then handing over to the Hospital at Home Social Work team.
- To ensure interdisciplinary communication and safe transition in to the Hospital at Home program by participating in interdisciplinary rounds and communicating frequently with both the in-home team and the command center team (virtual team) who will be managing the patient’s care during their Hospital at Home stay.
The successful candidate will have:
- Professional enthusiasm and commitment to patient and family experience.
- Creative problem solving and critical thinking skills to support coordination of care.
- Ability to plan, motivate and organize self, others and work in order to achieve objectives and targets.
- Exceptional interpersonal skills, with demonstrated ability to establish, maintain, and leverage positive, productive working relationships with individuals at all levels throughout an organization.
- Strong technical/computer skills with the ability to work in multiple applications and on various devices such as Microsoft Word, Excel, Teams, an electronic medical platform, a smartphone, and/or laptop.
- Determination to deliver outcomes and is able to overcome obstacles in order to move forward.
- Strong written, verbal and interpersonal communication skills with an acute ability to listen attentively and to communicate effectively throughout all levels of the organization.
- Group motivation, creativity and diplomacy.
- Highest-level customer service standards.
- Strong patient educational skills.
Weekend Day (United States of America)
EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.