The Care Coordinator is responsible for big picture focus of care transitions through the continuum. An integral part of the multi-disciplinary team, the Care Coordinator is responsible for ensuring quality patient outcomes, monitoring resource utilization and mitigating obstacles to care delivery through interdisciplinary collaboration, communication and coordination. This includes developing and carrying out discharge plans and mitigation of barriers that impede care progression. BSN Degree required within 3 years of start of position. Bachelor's degree not required in Critical Access Hospitals.

• Assesses for needs and develops individualized discharge plan.

• Identifies additional services needed and makes appropriate referrals.

• Leads and facilitates multi-disciplinary rounds. Helps to ensure clinical readiness for discharge.

• Collaborates with multidisciplinary team. Assists with throughput management and works to mitigate delays in care.

• In collaboration with attending physician, identifies appropriate length of stay and monitors resource utilization.

• Works with patients, families and caregivers to ensure patient needs are met, and a timely and appropriate discharge plan is implemented.

• Maintains appropriate documentation