Job Description

Location: St. Elizabeth's Medical Center
Posted Date: 12/8/2021

At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion, and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.

We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.

In support of this, we commit ourselves to the following values:






If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.

Position Summary: The RN Care Coordinator is responsible for overseeing the appropriateness of care provided to clinically complex patients admitted to the Medical Center. The RN Care Coordinator will be assigned to selected areas of the Medical Center on a rotating basis to perform discharge planning assessments and care coordination for patients with complex clinical needs based upon department staffing and coverage needs. The RN CC will support and coordinate the activities of the Social Workers assigned to the unit. As this is an evolving position, duties and responsibilities may vary based on specific assignments.

Accountability: Director of Care Management

Qualifications: Experience

  • Recent experience in acute care setting involved with clinical activities and/or a managed care environment working in case management
  • Recent experience in a case management or related role
  • Excellent computer skills including managing work against performance metrics and reporting on key indicators important to the department
  • Can function as a clinical expert and resource related to continuum of care and case management.

Education and Competencies:

  • Bachelor’s in Nursing required and master’s preferred (Nursing Masters not required for this advanced degree)
  • Strong computer skills with knowledge and proficiency with Microsoft Word, Excel, and PowerPoint
  • Strong data analytic skills to prepare and monitor management reports regarding the performance of the areas assigned and the Department
  • Demonstrated experience with managing against clinical and financial indicators and performance goals
  • Demonstrated skills in working collaboratively with physicians, managers, and other team members
  • Demonstrated skills in organizing and directing staff teams to complete assignments accurately and on time
  • Exempt position


  • Current licensure in Massachusetts as a Registered Nurse
  • Case Management Certification preferred
  • Evidence of continued professional development

Scope of Authority:

  • Support Social Worker (SW) Care Coordinator on the floor who will be responsible for the development and execution of patient discharge plans.
  • Help the SW Care Coordinators prioritize work and/or support clinically difficult discharge plans with the Social Workers.
  • Prepare and review reports on the Department’s performance including but not limited to - LOS, clinical denials and appeal status, avoidable days, time of discharge, proper level of documentation.
  • Work with Care Management Director to develop educational needs and identify strategies to accomplish objectives of the Department.
  • Given this job position is a new position; additional tasks may be added as the position is further developed.


Discharge Planning and Execution:

  • Identify the patients/discharges that are clinically complicated, managing the plan of care throughout the hospitalization. Develop a discharge plan that moves patient to appropriate next level of care needed for continued pursuit of optimum health and addresses any risk factors for unplanned hospital readmission for assigned patients.
  • Screen and assess patients and families to determine clinical, psycho-social and financial issues that impact discharge planning.
  • Provide patients and families with options regarding their discharge plan early in the hospital stay. Facilitate/Participate in patient/family care conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
  • Develop and implement a discharge plan focused on resources necessary to achieve patient care goals. Reassess plan throughout patient’s hospital stay and revise as necessary.
  • Evaluate patient and family needs to identify barriers to discharge and develop strategies to eliminate or reduce them.
  • Review initial Discharge Planning Assessments and proposed discharge plans performed by the Social Worker CC. Provide any feedback to Social Workers concerning cases.
  • Coordinate and monitor discharge planning activities for an assigned patient population and provide support to the Social Worker CC and administrative staff managing the discharge process.
  • Work with the discharge team and the PCPs/Hospitalists on creating an individualized discharge plan for high-risk patients, as needed, to ensure appropriate level of services are scheduled for the patient.
  • Educate clinical staff on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives.
  • Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health Agencies, physicians, and other staff to ensure all post-acute clinical information is provided. Information to be provided on a timely basis to not delay discharge.
  • Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate.
  • Provide patient education and family teaching, on an as needed basis.
  • Act as an advocate for the patient.
  • Promote nursing care within legal, ethical, and professional standards.
  • Facilitate/coordinate multidisciplinary care patient care rounds on medical/surgical units, as needed.

Other Responsibilities:

  • Communicate in real time with physicians on any patients not meeting criteria and establish a course of action. Work collaboratively with the MDs to help them understand documentation issues or any leveling issues. Provide education to them regarding Inpatient vs. Observation criteria or daily care criteria.
  • Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
  • Upon receipt of admitting or daily denials from insurers, review the case with RNCM UR reviewer and provide additional clinical information to reverse the denial.
  • Rotate to other units of the Hospital including the ED as directed by the Care Coordinator Manager and the schedule for the Department. Rotate and cover weekends and holidays, as directed by the CC Manager/Director. For all areas of the Hospital, perform all the functions stated in job description.
  • Maintain daily tracking tools, as needed, to help the Department collect data and track performance. Tracking tools to be developed by the Department. Examples of indicators to be monitored include (but not limited to):

      • LOS reports-
        • Identify long lengths of stay – report on reason for outliers
        • Identify short lengths of stay –under 24 and 48 hours and investigate possible observation, documentation in place for level of care
        • Monitor number of avoidable days

      • Inpatient to Observation conversion reports
        • Identify trends in inpatient admits being converted to Observation
        • Review dates of conversion – to ensure conversion happening prior to discharge
        • Review opportunities for MD education- ED MD and admitting MD/Hospitalists

  • Review with the CM Director management reports that provide Department performance metrics of Department and personal performance. Performance metrics to include but not limited to timely completion of discharge planning assessments and closing of referrals.
  • Review own personal performance and provide feedback in writing on how to improve performance on a routine basis.
  • Support the Care Management Director in maintaining the financial and clinical outcomes of the Care Management Department.
  • Support the Steward physician network by coordinating with the Steward ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community/ambulatory care coordinators are put in place.
  • Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
  • Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
  • Identify service needs, systems issues, and opportunities for improvement for the Department
  • Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
  • Report deviations in quality care to the Director of Care Management.
  • Assist with the development of clinical guidelines, as needed.
  • Maintain current knowledge of regulatory requirements including changes to payer requirements, reporting and regulatory requirements.
  • Demonstrate effective leadership skill
  • Attend Care Management staff meetings
  • Complete all paperwork required for regulations.

Performance Evaluations:

  • RN Care Coordinator will be evaluated based upon clinical and financial criteria where they influence the outcome. Some of these criteria include –but not limited to:
    • Discharge plan to achieve positive clinical and financial outcomes for assigned patients
    • Lengths of stay
    • Timely patient discharges – goal is 11:00am for patient discharge
    • Full use of Allscripts, Meditech.
    • Demonstrated collaboration with Social Worker CM, physicians, residents, and RNs on floor. This evaluation will be measured with feedback for other members of the care team
  • Information for staff evaluations will be collected by Department and will be made available for performance reviews. Selected data will be provided by the RN Care Coordinator. Other data will be provided by CM Director , Social Workers.

Additional Information

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.

Important COVID message

Please note, St. Elizabeth's Medical Center is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence, and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled, and professional way.

Application Instructions

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