Care Coordinator - SJ

Summary

• Position Summary
  • The care coordinator assumes responsibility and accountability for the collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to insure quality, cost-effective outcomes. Closely monitors length of stay for all assigned patients
• Education
  • Bachelors in Nursing - Preferred
• Experience
  • 3 - 5 Years Acute Care Setting - Preferred
  • Knowledge of regulatory agencies
• License & Certification
  • Professional License with State of Practice - Required
• Core Job Functions
  • Prioritize review of SDC and Observation patients to determine if ready for discharge. Perform brief assessment and readmission risk assessment within 24 hours. Confer with Utilization Management team member for daily update. Discuss discharge planning needs with patient, family and care team to determine most effective coordination of resources.
  • Perform chart reviews for unnecessary resource management. Denote relevant clinical information to UM for proactive communication to payers. Document avoidable days per department standard operating procedure.
  • Ensure patient/family/care giver is aware and agreeable of expected/anticipated day of discharge plan early in stay. Reassess and document discharge needs every 2 days. Collaborate with Social Workers for complex patient problem resolution. Discuss patient's discharge plan and needs with the patient/family and care team and document understanding or refusal of plan. Resolve outstanding or unanticipated discharge issues by communicating with patient/family and care team.
  • Proactively interact with UM and attending physicians to prevent inpatient denials. Follow payer requirements and government regulations to ensure compliant, safe and cost-effective care.
  • Identify patients with barriers to discharge as well as patients with a high risk of readmission. Identify high risk LOS patients or complex patients/situations and take actions to eliminate.
  • Identify anticipated discharge date for each patient each day. Provide insights on appropriate patient status and level of care throughout the patient stay to care team members during MDRs. Focus care team's attention on discharge planning, outliers and potential outliers. Present and discuss medical plan and transition plan of assigned patients at high risk LOS meetings.
  • Discuss barriers with attending, if unsuccessful, escalate to leadership and Physician Advisor.