Cobb Hospital.

Minimum 3 years of recent experience in hospital care coordination, working with patients/clients in transitional care services

Required Job Summary:

The Care Coordination Supervisor assists with coordination of patient care across the continuum during the patient's acute hospitalization. The CC Supervisor supports initial assessments, transitional care planning, patient advocacy, complex issue resolution, and monitoring performance for defined quality outcomes resulting from the care coordination services provided. The CC Supervisor support the CC Manager or Director and collaborates with all team members to provide an efficient and effective coordination of care. The CC Supervisor provides expert guidance in the following areas: Care Coordination comprehensive assessment and discharge (transition) planning Facilitative collaboration with multidisciplinary care team Effective and timely communication with care team and patient/family Challenging Conversations with patients/families Engagement with community agencies to ensure timely transfers and handoff of patient care. Patient/family education/counseling regarding medical recommendations of his/her conditions. Advance Directives Eligibility processes and criteria for both private and public, Local, State and Federal resources. Community resource information Financial needs assessment for patients in need of assistance for follow-up care Supporting patient care inclusive of cultural or religious beliefs Monitoring and resolving avoidable hospital days Continuous performance improvement

Core Responsibilities and Essential Functions:

Disposition Planning Oversight and guidance of

Team Members:

Implementation of effective and efficient discharge plan to include Plan A, B, C Effective collaboration with the multidisciplinary care team to streamline throughput and timely care delivery. Engagement with community agencies to ensure timely transfers and handoff of patient care. Provision of education/counseling to patient/family regarding medical recommendations of care. Responsiveness to referrals from hospital staff, physician offices, community and family to provide. resource information Financial needs assessment for patients in need of assistance for follow-up care throughout the continuum Leadership Duties Coordinate care with CC Manager/Director and other Healthcare Team Leaders. Oversee daily staffing assignments

evaluating daily work distribution regarding levels & demands of staff.

Coach, mentor team members on general practice. Manage QA & PI activities Provide guidance during the new team member orientation and onboarding Provides objective input and feedback for yearly performance

Assessment Oversight and Guidance of Team Members:

Quality of initial care coordination assessments for use in planning for appropriate right care, right setting in post discharge needs. Team members assessments of insurance and financial ability to participate in community care after discharge. Identification of issues and barriers relating to patients appropriateness of hospital stay and discharge needs. Documentation Oversight and guidance of

Team Members:

Initial psychosocial /functional assessment completed and documented in medical record. Complete chart notes accurately and timely per departmental protocol. Ensure all records are up-to-date and legible. Track and share avoidable days Identifies and provides training opportunities and continuous performance improvement for staff Trust/Engagement (Mandatory Content) Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level. Holds leaders accountable for behaviors that create trust and engagement. Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar. Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost effective delivery of quality patient care in a manner that fosters patient and employee satisfaction. Results Oriented Leadership (Mandatory Content) Sets challenging and productive goals for team. Holds team accountable for actions while providing leadership and motivation. Provides resources and support, Uses checkpoints and data to track progress, setting up system and processes to measure results. Collaboration and Partnership (Mandatory Content) Works collaboratively and as a team member with hospital leadership. Partners with Human Resources to achieve desired organizational culture, staffing and workforce metrics. Fosters positive working relationships between staff and physicians across the Health System. Fosters a culture that focuses on patient satisfaction, safety, customer service, staff participation, collaboration, motivation, and effective communication. Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelor's Degree BSN from an accredited school of nursing Master's Degree Social Work (MSW) from an accredited school of social work Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. LCSW

Lic Clinical Social Worker GA or LMSW
Lic Master Social Worker GA or MSW
Master Social Worker or RN
Reg Nurse (Single State) or

RN-COMPACT

RN•Multi-state Compact BLS•Basic Life Support or BLS-I•Basic Life Support•Instructor CCM•Certified Case Manager-Preferred or ACM•Accredited Case Manager-Preferred Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of recent experience in hospital care coordination, working with patients/clients in transitional care services

Required Required Minimum Skills:

Strong interpersonal skills. Knowledge of Case Management processes. Excellent verbal and written communication skills. Competency and confidence with crucial conversations in high stress environment. Knowledgeable in utilizing screening criteria in review of clinical data with respect to patients/clients needs for health care. Ability to effect change, performs critical analysis, promotes client/family autonomy. Ability to plan and organize effectively across the continuum of care. Independent and self-directed. Ability to multitask and work in a fast-paced environment a must. Expert knowledge of community resources, payor rules and regulations Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. 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