The Care Coordinator is a licensed or certified professional with a health, human services or nursing degree. Must have experience working with PT, OT, and SLP patients, preferably pediatric patients. This person is responsible for coordinating the delivery of care throughout the continuum of care for assigned patient population. Functions include case management, utilization management, quality data capture and discharge planning. The Care Coordinator works closely with the multidisciplinary team to actively facilitate those functions associated with moving the patient through an acute episode of care and linkages to community resources, internal resources and the payer community.
Essential Duties and Responsibilities
- Resource Management: Identify trends/problems related to delivery of care, delays and potentially avoidable days through consistent data capture. Application of severity of illness/intensity of service criteria for patients seeking inpatient admission or continued stay. On a concurrent basis, assess the appropriateness and timeliness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues and d completeness of documentation. Intervene with ancillary department leadership when timely service is critical to the patient's immediate needs. Interact with patients and physicians to explore the most appropriate setting to meet the patient needs.
- Transition Planning: Identify patients in need of post-acute care services. Make referrals to social work when patient or family needs psychosocial intervention to facilitate transition planning. Collaborate with team members to develop a transition plan appropriate to the patient's needs and ability to pay. Determine patient's eligibility for post-acute services within 24 hours of inpatient admission. Serve as consultant and educator to patient and family regarding post acute service recommendations. Convene and conduct interdisciplinary conferences to solicit input from clinical and business team members on selected patients. Collaborate with on-site payer representatives to advocate for patient's acute care and post acute care needs. Serve as liaison to community resources.
- Communication: Communicate patient needs to appropriate professional (i.e. social work, clinical pharmacist, clinical dietician); follow-up on communication. Communicate continually with patients and families, physicians, multidisciplinary team members and payers to facilitate coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum. Communicate with families to ensure understanding of payer guidelines and to arrange referrals.
- Clinical Management: Attend daily rounds and participate in setting priorities of patient needs. Confirm doctor's treatment plan and intended goals. Monitor the patient's progress toward the desired outcome. Collaborate with attending physician to establish treatment milestones to prepare patient and family for transition to lower level of care. Facilitate referrals to the appropriate areas to expedite care, treatment and services. Secure clinical resources essential to achieve the desired outcomes. Establish lines of communication with ancillary service managers. Collaborate with physicians, patients and families and nurses to identify probable post-acute care needs. Participate in the development, implementation, evaluation and ongoing revision of the plan of care, clinical pathways and initiatives to improve quality, continuity and cost effectiveness.
- Medical Documentation: Collaborate with Utilization Management, payers and Health Information Management staff to be knowledgeable regarding documentation. During point-of-service rounds with the physician, offer suggestions for more accurate and complete documentation. Share written information with physicians to inform and educate on the dimensions of accurate documentation.
- Process and Performance Improvement: Work collaboratively with other departments and services to define and study areas of inefficiency and participate in process improvement projects. Be involved in the development of strategies and plans to maximize the most appropriate use of services in assigned areas.
- Ability to meet physical and non-physical demands as outlined in the job description is an essential function of the job
- Two-year Associate's degree or equivalent required
- Four-year Bachelor's degree preferred
- Graduate of accredited school of nursing required
LIcenses & Certifications
- Registered Nurse, current license to practice professional nursing in the state of Texas required - requires Case Management or Rehabilitation experience.
- Licensed or certified health or human services professional in either Social Work or Case Management
- CPR required
- Certified Case Manager preferred
- Minimum 4-5 years of related experience required
- Case Management, Utilization Review, Home Health Care, Discharge Planning, Pediatrics preferred
Specific knowledge, skills, and abilities
- Physical and emotional health adequate for performance, which may require extended or flexible work hours, rapid assessment and response to patients, families and employees
- Ability to influence action; "care" to advocate for change; collaborate with and complement the clinical members of the patient's healthcare team; communication in an assertive yet responsible way
- Have the requisite clinical knowledge to enter into a partnership with key customers
- Analytical ability to effectively prioritize, assess, plan, coordinate and evaluate the care of patients and their families to achieve quality and cost effective outcomes
- Effective interpersonal skills with positive relationship building; effective written/verbal communication; ability to negotiate with interdisciplinary team members, physicians, families, payer sources and peers
- Knowledge of evolving healthcare systems, including but not limited to funding sources, third party reimbursement, contractual arrangements, managed care, continuum of care issues, disease management and clinical guidelines
- Evidence of self-direction, flexibility, adaptability, creativity, ability to prioritize efforts, ability to multi-task and effective time management
- Is knowledgeable of and acts in accordance with laws and procedures regarding patient confidentiality
- Experience with using personal computers
- Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly OR requires walking or standing to a significant degree.