Clinical Episode Coordinator- Hamilton, NJ

Job Summary

The Clinical Episode Coordinator will utilize skilled intervention, clinical best practice knowledge and collaboration with the patient, physician and multidisciplinary treatment team to pace care, achieve quality outcomes and negotiate appropriate reimbursement. The Clinical Episode Coordinator will ensure the timely and seamless clinical transition of patients through medically appropriate levels of care.

Essential Job Functions

• Serves as a critical component of the value-based operations care management team. He or she will oversee coordination of care for all patients enrolled in one or more value-based programs including CJR, MSSP, HRRP, and all other contracted programs while the patient is in an acute care setting.

• For Medicare patients enrolled in Comprehensive Joint Replacement (CJR) lives, the Episode Coordinator’s responsibility includes engaging the patient directly at the bedside, providing the beneficiary notification, and working with the patient’s interdisciplinary team which includes the patient, family, caregiver, Orthopedic service line coordinator, and clinical care team to coordinate an appropriate and safe discharge plan to a post-acute or home setting.

• For Medicare patients enrolled in a Medicare Shared Savings Program (MSSP) and/or Hospital Reduction Readmission Program (HRRP), the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify next site of care discharge disposition.

• For all other contracted payers under population health, the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify next site of care discharge disposition.

• Conduct a follow up phone call after the patient has been discharged from an acute care setting to home, to screen patients for safe discharge, and escalate any clinical issues to a Nurse Care Manager as needed for clinical interventions.

• Reports directly to the centralized value-based operations care management team ensuring strong alignment and continuity of care for patients to avoid any overlapping outreach.

• The Episode Coordinators will be provided with a risk stratification tool and Value Based Care criteria to focus and prioritize efforts.

Essential Job Functions Cont.

• Identification of CJR, MSSP, HRRP, and other patients attributed to a value-based contract upon admission:
  • CJR patients are identified through the Ortho Service Line daily, via an Excel list that is provided to the Episode Coordinator’s via a Shared Drive (patient tracking tool)
  • MSSP and other value-based patients (Non/CJR patients) are identified through the Acute Admit program in Epic
  • HRRP lives are identified through the HRRP program in Epic
  • Email list of all CJR, MSSP, and CJR lives to (IP CM, PT, etc.) to identified key stakeholder daily
  • Episode Coordinator will stratify patient list each day and send patient list and assigned Care Manager to individual Inpatient Case Managers to alert them of VBC patient and initiate comprehensive discharge planning
• Bedside visits:
  • Sign patients up for My Chart
  • Schedule PCP follow up appointment.  If the patient does not have a PCP – assist patient in selecting a PCP and making the initial appointment
  • Ensure any specialist appointments are scheduled as needed
• Engagement with CJR patients:
  • Distribution of Beneficiary Notification Letter for ER to Admission patients
  • Documentation of date/time letter give to patient
  • Confirming contact information and document information
  • Documentation of patient data and information in Epic Healthy Planet for CJR, MSSP, HRRP, all value-based contracts patients. Specific documentation focuses on care at time of discharge within Epic: what happened, where they went, both level and name of facility, if applicable
  • Engagement with Care Management Director and Physician Advisors
  • Identify units with highest volume of VPC patients and discuss care planning, in real time, individual patients on the daily census
  • Daily touch base with Unit Case Management to facilitate appropriate next site of care
  • Actively communicates with discharge planners about patients with Post-Acute Care facility needs
  • Communication with Post-Acute Coordinators on patients going to facilities
  • Communication to Population Health Nurse care manager and VNA on patients going home with or without Home Health
  • Inform Case Management of readmissions

Job Qualifications

• Bachelor's in Nursing, required 
• Current Active NJ RN License, required 
• At least one year Case Management experience, preferred