The Case Manager Care Coordinator coordinates the care and service of patient populations from admission through discharge. The Care Coordinator clinically assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs to facilitate a safe and timely discharge to the next appropriate level of care. The Care Coordinator works collaboratively with inter-disciplinary teams to build a comprehensive case management plan through effective care coordination and utilization of healthcare resources in order to achieve desired clinical and financial goals.
The Care Coordinator's key responsibilities are to partner with the healthcare team to ensure all aspects of the patient's needs, clinical, psycho social and financial are adequately addressed in the transition of care plan and to manage the patient's timely progression of care and safe transition to the next most appropriate level of care. Responsibilities Conducts an in-depth case management assessment of a patient’s needs at the time of admission and throughout the patient’s stay.
Obtains and confirms information necessary for the development of a comprehensive discharge/transition plan of care. Reviews all clinical findings and diagnostic reports to maintain a comprehensive understanding of the patient’s current plan of care. Correlates the medical record findings with patient assessment findings and works with physicians to develop a comprehensive case management and transition plan of care.
Works with the Utilization Review Case Manager to monitor resource utilization and validate that the patient is in the most appropriate level of care based on Federal, State and other payer guidelines. Works closely with physicians, nurses, social workers, ancillary staff and other members of the healthcare team and collaboratively communicates assessment findings and care transition recommendations to achieve targeted outcomes and meet all patient needs.
Proposes solutions to address barriers to discharge to the healthcare team to ensure an efficient and effective transition plan of care. Identifies and reports potential physician-related barriers to discharge or timely care coordination to the physician advisor. Actively coordinates the patient’s care by monitoring the length of stay (LOS) of the patient’s hospitalization, leads and facilitates the Progression of Care Rounds, and proactively works to meet expected length-of-stay and clinical targets/indicators.
Identifies the need for home care services including durable medical equipment and home infusion services as early as possible in the patient’s hospitalization and completes timely comprehensive referrals and arrangements for these services. Facilitates the transfer of patients to other acute care hospitals and efficiently coordinates referrals to Long Term Acute Care Hospitals (LTACH) and Skilled Nursing Facilities (SNF) and subsequent discharges to these facilities.
Maintains expert knowledge of payer/reimbursement rules and regulations related to care coordination and discharge/transition planning processes. Works collaboratively with Case Management Assistants and Social Workers to ensure the “Important Message from Medicare” letters are given to patients within a 48 hour timeframe prior to discharge or no later than 4 hours prior to discharge on the actual day of discharge. Addresses system-level issues impeding diagnostic or treatment progress with the healthcare team and reports unresolved opportunities for improvement through the organizational defined escalation process, (chain-of-command structure).
Proactively identifies and resolves barriers to timely discharge/transition and documents ‘avoidable day’ information in CS Link. Promotes the understanding and use of Advance Directives, POLST, and ensures patient’s wishes regarding end-of-life are understood and respected. Identifies the primary patient/family decision maker and communicates care plans and other information regarding the plan of care, the transition plan and expected outcomes of these plans.
Maintains knowledge of Federal, State, and other regulatory agency rules and regulations including The Joint Commission, CMS, Medicare, to include at minimum, knowledge of CMS rules regarding Observation status, the 2 Midnight Rule, and Medicare Inpatient Only Procedures. Education Bachelor's Degree Nursing - preferred Assoc. Degree/College Diploma Nursing - minimum Experience 2 years In acute care nursing - Medical Surgical/Tele/ICU/LTACH or 1 year in acute care nursing (Medical Surgical/Tele/ICU) with 2 or more year of care management experience (UM or DC Planning). - minimum Licenses and Certifications RN State License - Upon Hire minimum Acute nursing experience Basic Life Support (BLS) - Upon Hire minimum BLS Required Certified Case Manager - 2 years preferred Experience and certification in case management preferred