RN Clinical Care Coordinator
1 week ago
Job Overview:
The RN Clinical Care Coordinator is a critical component of the value-based operations care management team. The RN Clinical Care Coordinator will oversee the coordination of care for all patients enrolled in one or more value-based programs, including CJR, MSSP, HRRP, and all other contracted programs, while the patient is in an acute care setting and after discharge.
For Medicare patients enrolled in Comprehensive Joint Replacement (CJR) lives, the Episode Coordinator s responsibility includes engaging the patient directly at the bedside, providing the beneficiary notification, and working with the patient s interdisciplinary team, which includes the patient, family, caregiver, Orthopedic service line coordinator, and clinical care team to coordinate an appropriate and safe discharge plan to a post-acute or home setting.
For Medicare patients enrolled in a Medicare Shared Savings Program (MSSP) and/or Hospital Reduction Readmission Program (HRRP), the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify the next site of care discharge disposition.
For all other contracted payers under population health, the Episode Coordinator will participate in interdisciplinary rounds and coordinate with the hospital care team to identify the next site of care discharge disposition.
Qualifications:
Required:
- Bachelor's in Nursing, required.
Preferred:
- At least one year Case Management experience, preferred.
Certifications and Licenses Required:
- Current Active NJ RN License, required.
Essential Job Functions
- Identification of CJR, MSSP, HRRP, and other patients attributed to a value-based contract upon admission:
- CJR patients are identified through the Ortho Service Line daily via an Excel list that is provided to the Episode Coordinator via a Shared Drive (patient tracking tool)
- MSSP and other value-based patients (Non/CJR patients) are identified through the Acute Admit program in Epic
- HRRP lives are identified through the HRRP program in Epic
- Documentation of patient data and information in Epic Healthy Planet for CJR, MSSP, HRRP, and all value-based contracts patients. Specific documentation focuses on care at the time of discharge within Epic: what happened, where they went, both level and name of the facility, if applicable
- Engagement with the Care Management Director and Physician Advisors
- Identify units with the highest volume of VPC patients and discuss care planning, in real-time, with individual patients on the daily census
- Daily touch base with Unit Case Management to facilitate appropriate following site of care
- Actively communicates with discharge planners about patients with Post-Acute Care facility needs
- Communication with Post-Acute Coordinators on patients going to facilities
- Communication to Population Health Nurse care manager and VNA on patients going home with or without Home Health
- Receive a risk stratification tool and Value-Based Care criteria to focus and prioritize efforts.
- Conduct follow-up phone calls after the patient has been discharged from an acute care setting to home to screen patients for safe discharge and escalate any clinical issues as needed for clinical interventions.
- Reports directly to the centralized value-based operations care management team, ensuring strong alignment and continuity of care for patients and avoiding any overlapping outreach.
- Inform Case Management of readmissions
Essential Job Functions Cont.
- Bedside Visits:
- Sign patients up for My Chart
- Schedule PCP follow-up appointment. If the patient does not have a PCP assist the patient in selecting a PCP and making the initial appointment
- Ensure any specialist appointments are scheduled as needed
Engagement with CJR patients:
- Distribution of Beneficiary Notification Letter for ER to Admission patients
- Documentation of date/time letter given to patient
- Confirming contact information and document information
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.
- Paid Time Off (PTO)
- Medical and Prescription Drug Insurance
- Dental and Vision Insurance
- Retirement Plans
- Short & Long Term Disability
- Life & Accidental Death Insurance
- Tuition Reimbursement
- Health Care/Dependent Care Flexible Spending Accounts
- Wellness Programs
- Voluntary Benefits (e.g., Pet Insurance)
- Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more
Choosing RWJBarnabas Health
RWJBarnabas Health is the premier health care destination providing patient-centered,
high-quality academic medicine in a compassionate and equitable manner, while delivering
a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.
RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.
Equal Opportunity Employer
#LI-AB1
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