Clinical Care Coordinator Denials RN, Case Management, Full Time, Days

Department: Jackson Memorial Hospital - JM Case Management Acute

Address: 1611 NW 12 Ave, MIami, FL 33136

Shift details: Full Time 8:00 am - 4:30 pm, Monday-Friday

Why Jackson Memorial Hospital: Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century. Throughout its rich and storied history, Jackson Memorial - located in the heart of the City of Miami - has been ground zero for some of the world's greatest medical breakthroughs and important moments in South Florida. We've grown into one of the nation's largest public hospitals, and one of the few that is also a world-class academic medical center with a proud mission and proven success. Jackson Memorial is an accredited, tertiary teaching hospital with 1,500 licensed beds, where nearly every medical specialty is provided by some of the world's most skilled and highly regarded multidisciplinary team of healthcare professionals.

Summary

The Clinical Care Coordinator is a professional member of the health care team who assumes advocacy and accountability and works in collaboration and continuous partnership with chronically ill or high-risk patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to provide a continuity of the single standard of care.

Responsibilities

• Performs independently in coordinating and tracking patient care, and providing discharge planning for patients. Provides discharge /educational instruction for patients/families. Collaborates with appropriate resources in implementing educational programs. 
• The CCC participates in the development of the plan of inpatient care, according to patient specific age and/or developmental needs. 
• In collaboration with the multidisciplinary health care team, the CCC utilizes clinical pathways in support of the provision of care. 
• The CCC collaborates with other health care team members and with external payer sources in the delivery and coordination of care during a single episode of hospitalization through discharge to home or to next level of care. 
• Also responsible for tracking of quality measures related to care coordination efforts. 
• Screens patient records, as assigned, using specific criteria and critical judgment, in order to identify adverse events, sub-optimal patterns or care and or utilization. 
• Reviews pertinent documentation, interprets clinical data; identifies variations in care and or utilization based on knowledge of disease processes and appropriate treatment modalities, relevant data. 
• Analyzes data which has been collected, evaluates current practice, draws conclusions and makes recommendations for changes or improvement as appropriate and monitors the status of resolution of identified issues. 
• Reports adverse event, as appropriate, summarizes findings and maintains accurate records of all reviews performed. Includes review of incident reports, complication reports from all departments, patient satisfaction survey comments, mortality reports. 
• Coordinates physician peer review committees (Special Medicine, Surgical, Psychiatric, anesthesia and Obstetrics Committee) and prepares and/or presents information to appropriate committees, forums, as requested. 
• Collaborates with medical staff to review and interpret medical staff monitoring activities relative to the quality and appropriateness of patient care, the utilization of resources, and collaborates with Risk Management, as appropriate. 
• Works closely with JMH Clinical Performance Specialist and other JMH staff who are responsible for maintenance, review and updating of the Nursing Standards Manual and Red Book Policies. 
• Coordinates review of those policies and procedures that are being addressed at General and Critical Care Policies and Procedures (P&P) committees with the appropriate departments/management staff and obtains appropriate feedback/recommendations. 
• Facilitates completion and update policies and procedures that are not integrated with assigned facility. 
• Ensures final integrated policy and procedures/forms are placed in the current computer system file and the old P&P is archived. 
• The index is updated to direct staff where to find P&P and forms. 
• Facilitates monthly unit educators meeting to provide policy/forms and updates. 
• Ensures hospital-wide Red Book manuals are updated with new revisions.
•  Participates in hospital-wide quality improvement activities. 
• Maintains knowledge of JCAHO standards and assists with preparation for JCAHO survey. 
• Conducts record review audits and unit inspections to assess JCAHO readiness compliance. 
• Participates in community seminars and continuing education programs in order to enhance own knowledge base and to exchange appropriate information with peers. 
• For CCC working as Observation Liaison: assess complex patient care needs/situation/acuity levels obtaining significant date from assessments (physical/function, mental, psycosocial, environmental, family support, spiritual, cultural, financial, legal). 
• Coordinates patient care through out an episodic / continuous course of care for a specific DRG/diagnosis/procedure/population using InterQual, Millikan or other specific criteria and evidence based guidelines. 
• Completes electronic documentation for case management activities such as discharge planning, patient throughput, appropriate level of care, communication with physician, nursing and patient / family member. 
• Articulates information pertinent to clinical condition, LOS, discharge delays, outcomes, resource utilization, discharge planning, etc. at the team meetings / presentations, patient care rounds, interdisciplinary rounds and to administration, medical director and physician advisors. 
• Demonstrates effective interpersonal communication skills through the development and maintenance of productive working relationships with medical staff, nursing, ancillary departments, administrative staff and peers. 
• Follows and performs all related unit specific policies and procedures, as detailed on the unit specific competency check-list. 
• Utilizes job and unit specific equipment as required. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). 
• Performs all other related job duties as assigned.

Experience

Generally requires 3 to 5 years of related experience.

Preferred Experience

• At least 3-5 years' experience as a denials/appeals coordinator.
• Experience in clinical documentation improvement (CDI), strongly preferred. 

Education

BSN or Bachelor's degree in related field is required. Master's degree is preferred.

Credentials

• Valid Florida RN license is required. 
• American Heart Association Basic Life Support (BLS)and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment. 
• Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty.