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SalaryJob Description
Job Duties
Insert “*” to classify Essential Function
% of Time (must total 100%)
On a concurrent basis the Care Coordinator (CC) utilizes appropriate/standardized criteria to determine the optimal level of care required for the patient and alternate care delivery options. On concurrent basis, assesses the appropriateness of the level of care/care management; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness. Records variances through the established care coordination and quality improvement processes. Documents all reviews in designated software system. Conducts admission and concurrent medical record review using established medically necessity criteria as described by policy in accordance with regulatory and contractual requirements as well as internal policy. Screens for appropriateness of admission (IP vs. Observation) and continued stay for medical necessity. Escalates as appropriate per policy Reviews clinical and demographic information for accuracy and completeness to ensure that hospital care delivered meets payer requirements for observation or inpatient services. Acts as a resource and provides staff and physician education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery. Assists in monitoring critical care bed utilization.
*
25%
Ensures patient progression through the continuum in an efficient, cost effective manner in collaboration and communication with patient/family, physicians and the interdisciplinary team. Acts as patient advocate by negotiating for and coordinating resources with agencies and vendors during inpatient and transitions to post-acute care.
Performs initial Care Management assessment to determine care coordination and discharge planning.
Coordinates and implements the discharge plan for patients with post- acute care needs in collaboration with the Social Worker Identifies patients/family for Social Worker referral who would benefit from support needed to better enable patients/family in dealing with impact of illness on family functioning and achieving maximum benefits from healthcare services.
Participates in ongoing communication with physician to develop a collaborative relationship aimed at improving clinical treatment goals and appropriate and timely discharge for the patient. Comprehensively assesses patient’s biophysical, psychosocial, and environmental needs focused toward discharge planning initiatives - makes appropriate referrals.
Provide expertise and support to the treatment team regarding the management of chronic disease/complex patients.
Identifies and participates in the development of strategies to reduce unnecessary LOS, resource consumption, implementing and documenting results.
Provide expertise to the team in developing treatment and discharge planning strategies for frequently admitted patients.
Ensures that the proper sequencing and scheduling of interventions, treatments and procedures are in accordance with the patient’s treatment plan, that care is expedited, and care delays and denial of payment are avoided.
Identifies (internal and external) variances/obstacles to efficient or timely care and positive patient outcomes and intervenes with the healthcare team to overcome or eliminate these when possible.
*
25%
Interacts with or provides information for third party payers/review agencies to coordinate certification requirements, LOS treatment planning and other benefit utilization issues. An established procedure is utilized to resolve denial of care, conflicts over care, service or payment. Assists in coordinating pre/post hospital care within SEH, providers, and community health services. Coordinates the utilization of benefits and resources in the course of care. Works and communicates the plan of care effectively with patient/family; medical staff; caregivers, healthcare team members and third-party payors. Works confidently to identify an effective approach to task/problem. Communicates with patient to ensure understanding of discharge planning referrals as ordered by physician and third-party guidelines. Assists with negotiation of financial arrangements for reimbursement for out-of-network services.
*
20%
Document patient medical necessity criteria and discharge planning activities according to departmental policies. Completes data collection via designated software for all patients. Identifies and documents risk management, quality and infection control issue and communicates to appropriate departments/services. Communicates only appropriate necessary information on chart applicable to the referral source in accordance with HIPPA guidelines.
*
15%
Stays abreast of changing clinical trends, criteria, regulatory matters and third-party payer requirements related to clinical care, discharge planning and precertification of after care benefits along with Medicare, Medicaid guidelines, rules and regulations. Participates in the development of process/systems to measure/monitor clinical practice. Obtains reviews and analyzes LOS, resource utilization, outliers, readmissions, denials and delay days for assigned patients. Attends organizational committees, arriving on time and prepared, and implements/communicates information. Engages in educational opportunities to maintain professional competencies.
*
5%
Provides to patients, families, and hospital staff education regarding post-acute services (home health services, ECF, Hospice, etc. Opportunities for conducting education may include patient families at bedside, one-on-one staff education, and unit department meetings.
*
5%
Performs other duties as assigned.
5%
TOTAL:
1 00%
Qualifications
Education, Credentials, Licenses:
Graduate of an accredited baccalaureate school of nursing or related field. Licensed as an RN to practice nursing in the state where work is being performed. Meets contact hour requirements for licensure, including all state required courses.
Specialized Knowledge:
Knowledge of state and federal regulatory issues, payor strategies, payment methodologies, benefit plan designs and limitations. Working knowledge of SEHC policies and procedures. Good organization, critical thinking, problem solving, and communication skills. Excellent human relations skills and team leadership abilities.
If, for any reason, you are having difficulties applying, please contact our recruitment team at recruiting@stelizabeth.com
