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Medical Center Hospital Care Coordinator in Odessa, Texas

Care Management Department

Care Coordinator RN

Job Description

Revised: 03/05/2015

  • Position Summary:

The Care Coordinator Registered Nurse is responsible for leading the interprofessional team in continuity of care and discharge planning. The Care Coordinator facilitates integ1 rated and comprehensive patient services during hospitalization. The Care Coordinator provides ongoing assistance and consultation to the healthcare team through a comprehensive assessment of patient needs, planning and implementation of an interprofessional care plan, and communication of individual patient needs.

  • Position Relationships:

A. Responsible to: Director of Care Management

B. Workers Supervised: None

C. Interrelationships: Works in collaboration with UOM Staff and

Hospital staff. Works directly with physicians

and health care professionals who are

providing care and service. Works closely with

patients and their families. Has frequent

contact with multiple community healthcare

providers, community resources and referral


  • Responsibilities and Authorities:

  • Performs other duties as assigned by the department's management staff.

  • As patient care and/or Hospital need dictates, both the assigned shift and work station may be changed by the department.

  • Participates in and promotes the “I CARE” service philosophy of Integrity, Customer Centered, Accountability, Respect and Excellence. Treats all customers with courtesy, dignity, respect and professionalism.

  • Performs essential job functions with or without reasonable accommodations.

  • Completes in-depth assessment of patients within a specified time to include their health status, comorbidities, level of function, psychosocial situation, and discharge needs; medications, equipment, follow-up appointments.

  • Assists in identifying patients that are considered “High Risk” for hospital readmission based on assessment and designated tool(s).

  • Leads interprofessional team in establishing a comprehensive care plan to promote continuity of care.

  • Assesses patient discharge needs and coordinates discharge plan in conjunction with physicians, charge and primary nurse, other healthcare team members, and community nurse navigator(s).

  • Seeks out information and to facilitate complex discharge planning and utilization needs.

  • Provides educational support to patients and families, physicians, and health care staff on discharge barriers, collaborative practice, levels of care and psychosocial concerns.

  • Documents all care coordination and discharge planning needs in the patient’s medical record and plan of care.

  • Communicates routinely with patients, families and members of the health care team regarding discharge plans, potential barriers and necessary resources.

  • Maintains a collaborative relationship in order to enhance understanding and cooperation with Health Care Team.

  • Refers matters of potential conflict immediately to the attention of the Direct Supervisor.

  • Performance Factors Used to Evaluate Employee:

  • Makes appropriate adjustments in assessments, plans, and interventions for the following age groups: 1. Neonates 4. Adults 2. Pediatrics 5. Geriatrics 3. Adolescents

  • Provides psychosocial assessments of patients and families to identify emotional, social, and environmental strengths and problems related to their diagnosis, illness, treatment, and/or life situation.

  • Maintains a working knowledge of relevant medical/legal issues that impact patient care, e.g., advance directives, child and elder abuse, etc.

  • Coordinates patient/family discharge needs.

  • Arrange, procure, and coordinate patient/family post hospital needs.

  • Works with close collaboration with the community nurse navigators to effectively manage the transition for hospital to home.

  • Demonstrates an attitude of cooperation and enthusiasm in support of all departmental and hospital endeavors.

  • Maintains HIPAA compliance.

  • Demonstrates effective time management, extensive organization skills and self-direction.

  • Demonstrates productive problem-solving techniques, interpersonal relations and communication strategies.

  • Qualifications:

A. Education:

A current licensure as a RN with the Texas State Board of Nurse is required. Certification in Case Management (CCM) and a Bachelor’s Degree in Nursing are preferred.

B. Training and Experience:


  • Minimum of 1 to 3 years of acute care experience;

  • Minimum of 1 to 3 years of case management experience preferred; and

  • Basic knowledge of health plan products, community resources and alternative funding programs. C. Unusual Physical Demands and Working Conditions: Must be able to move about hospital without major constraints. Universal precautions are maintained at all times. Must be able to work long hours on occasion and work well under tight deadlines.