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Care Coordinator RN - 16341

Full Time

Danbury, CT, USA

Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — 

Performs assessments and formulates discharge/transition plans in collaboration with patient, family and multidisciplinary healthcare team. Provides ongoing monitoring and evaluation of plans to meet the individual needs of patients throughout the care continuum. Assists in resource management through facilitation of care and participation in program planning, data collection and analysis. Provides education to patients/families regarding coverage, care options and community resources.



  •  Care Coordination/Facilitation and Transition Management - coordinates multiple aspects of care to all appropriate patients to ensure the patient progresses through the hospitalization. Makes the transition to the next level of care with the services required to promote high-quality outcomes.
  •  Assists in the development of the patient's plan of care and ensures the plan is implemented timely. Discusses with the healthcare team identified delays while providing direction, assistance and support in developing strategies and interventions to move patient through the continuum of care. Follow up on any delays and help expedite diagnostics and treatments. Assesses patient's clinical readiness for transition in collaboration with the healthcare team and informs the team of the available resources based on the patient's clinical needs. Initiate paperwork to transfer information to the community providers timely. Maintains easy flow of communication regarding patient's development and progress to all involved in care of patient.
  •  Participates in the development and improvement of clinical initiatives focused on reducing LOS, Denials, Re-admissions and ensuring appropriate levels of care. Actively involved in all daily, weekly rounds/meetings. Knowledge of hospital and community resources and is a resource for the healthcare team.
  • Maintains effective relationships and a positive outlook when interfacing with other departments, multidisciplinary healthcare team as well as patient's/families and community providers.
  • Acts as an intermediary between patients, physicians and community providing advocacy, accurate healthcare information, potential referral services and proper treatment plans. Initiates and coordinates patient care conferences as required.
  • Provides clinical social work interventions which include counseling, bereavement and crisis intervention as well as assessment and intervention in cases involving complex family/patient dynamics.
  • Care Coordinators in utilization review audits all admissions and continued stays for assigned group of patients to determine certification to the assigned level of care utilizing standardized criteria to achieve optimal outcomes and reimbursements. Provides timely clinical information to the commercial insurers. Coordinates direct communication between MD's and insurers to proactively avoid denials. Identifies variances, avoidable days, readmission and LOS issues and works with department leadership and the healthcare team to develop changes in process to improve outcomes. Collaborates with other members of care coordination to communicates changes in level of care as well as other pertinent information required for an optimal transition plan. Provides education to patient/families and the healthcare team.
  • Care Coordinators in high risk coordinate care for a group of patients with a specific diagnosis and/or complex discharge needs across the continuum. Provides assistance and support in collaboration with the healthcare team to ensure that patients are given all available resources to meet their healthcare goals and improve self-management of their health/disease process.

Minimum Experience: three years

Desired: BSN or equivalent education and experience. CCM and/or ACMA certification or equivalent.
Location: Danbury-24 Hospital Ave

Work Type: Full-Time

* Registered Nurse

* Associate's Level Degree

Salary Range: 39.72 - 72.01

Company Description:

Health Quest and Western Connecticut Health Network have combined to form a new nonprofit health system. The name for the new health system will be Nuvance Health. The new health system was created to provide communities across New York’s Hudson Valley and western Connecticut with more convenient, accessible and affordable care.