Job Description

Location: Carney Hospital
Posted Date: 12/23/2020

INTERNAL 12/23/20 - 12-30-20

TITLE: Care Coordinator


DEPARTMENT: Care Coordination


REPORTS TO: Director of Care Coordination



  • The Care Coordinator is a registered nurse who will work as a member of the health care team to coordinate patient care and services across the continuum, as well as promote and monitor effective and efficient utilization of resources. The individual will demonstrate clinical expertise in applying nursing processes, documenting skilled needs within regulatory insurance guidelines, in matching community resources to the specific plan of care in collaboration with hospital and community providers. The individual will function as a role model, collaborator, educator, consultant and change agent in the areas of continuity of care and utilization review.


  • Assess all new admissions to the assigned nursing unit on a daily basis to determine possible discharge planning needs.
  • Assessment includes the patients’ goals, as well as their biophysical, psychosocial, environmental, spiritual, cultural, financial, and discharge planning needs.
  • Refer patients and/or families to appropriate resource as necessary, i.e. social service, financial planning, legal services, etc.
  • Collaborate with the health care team to develop and implement a discharge plan when need is identified in initial assessment..
  • Document the plan of care in the medical record in a timely, accurate and concise manner. Update information as it changes to keep health care team members aware.
  • Act as advocate on behalf of patients and families for appropriate services.
  • Maintain expert knowledge community resources available for discharge planning purposes.
  • Educate health care team members, patients and families regarding community resources.
  • Act as Liaison to community providers and extended care facilities.
  • Communicate continually with patients, families, health care team members and third party payors as necessary.
  • Identify quality and risk management concerns and report them to the Quality/Risk Management Department.
  • On a concurrent basis, assess the appropriateness of the level of care for admission and continued stay.
  • Ensure that the medical record documentation supports the plan of care as discussed with the health care team.
  • Communicate concerns regarding utilization review and discharge plans to the health care team members.
  • Collaborate with team members to effectively address and resolve those concerns.
  • Communicate with third party payors on admission and continued stay authorizations as well as discharge plan approval when necessary.
  • Maintain current knowledge regarding regulatory requirements as pertains to utilization review and discharge planning.
  • Educate health care team members, patients and families on third party payor and regulatory requirements
  • Participate in meetings, reports, and other activities that support the function of the health care team.
  • Maintain confidentiality in all professional situations regarding ‘protected health information’.
  • Demonstrate support of hospital CORE values.
  • Participate in continuing education for professional development.
  • Maintain professional licensure in good standing.
  • Responsibilities may change as this is a new and evolving role.
  • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

1. Commits to recognize and respect cultural diversity for all customers (internal and external).

2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

  • Performs other duties as assigned


  • Excellent interpersonal skills with all levels of internal and external customers.
  • Excellent assessment, problem solving and planning skills.
  • Excellent communication and negotiation skills.
  • Ability to work independently and efficiently.
  • Ability to prioritize appropriately.
  • Ability to be attentive to detail and follow-up.
  • Ability to establish and maintain a teamwork environment with heath care team members and outside agencies.
  • Computer skills


  1. Education: Graduate of a NLN accredited School of Nursing. Bachelor’s degree in nursing or a related health field
  2. Experience: Minimum of 5 years nursing experience preferably in a variety of settings (hospital, home care agency, rehab or long-term care). 2 years current experience in discharge planning and/or utilization review activities.
  3. Certification/Licensure: Current licensure as a registered nurse in the Commonwealth of Massachusetts.
  4. Software/Hardware: Computer skills
  5. Other:

Application Instructions

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