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Patient Care Coordinator
2 months ago
Overview:
The Patient Care Coordinator (PCC) plays a crucial role in working alongside patients, families, healthcare providers, and interdisciplinary teams to ensure seamless patient care throughout their healthcare journey. The PCC is responsible for crafting individualized care plans for each patient, guiding them from admission to discharge. This position emphasizes optimizing patient flow and enhancing the overall quality of care, patient satisfaction, and safety while managing the length of stay effectively. The PCC conducts thorough assessments, strategic planning, implementation, and evaluation of patient needs, focusing on care coordination and discharge planning as key responsibilities. The PCC identifies and addresses patient and family needs by collaborating with team members and resolving any obstacles that may impede effective care delivery.
Key Responsibilities:
• Uphold the standards of OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Conduct interviews with patients and families to gather information regarding social, emotional, and financial factors affecting health status before and after discharge, assessing the current support systems and available resources.
• Collaborate with senior care managers to develop and monitor the patient's care plan, ensuring service effectiveness and appropriateness.
• Facilitate patient care progression across the continuum in a cost-effective manner.
• Act as a resource and advocate for patients regarding treatment decisions and end-of-life considerations.
• Monitor patient length of stay closely, communicating with interdisciplinary team members to eliminate barriers and expedite discharge.
• Identify and escalate local and systemic barriers that hinder diagnostic or treatment progress, addressing quality and risk issues promptly.
• Work towards resolving identified discharge delays.
• Collaborate with medical, nursing, and ancillary staff to ensure efficient care delivery in the appropriate setting.
• Assess discharge planning needs and continuing care/resource support after discharge, making independent recommendations regarding post-acute care options, including:
• Rehabilitation Placement
• Skilled Nursing Placement
• Psychiatric or Substance Abuse Placement
• Home Health/Hospice Referrals
• Community Resource Needs
• Financial Issues/Funding Options
• Social Determinants of Health
• Ensure effective communication and updates are provided to patients, families, and healthcare team members, documenting as necessary to maintain continuity of care.
• Provide interventions that reflect knowledge and sensitivity to cultural diversity and the varied backgrounds of the patient population.
• Assist patients and families in accessing necessary resources within the healthcare system and community.
• Maintain consensus on care plans among patients, families, physicians, and payors.
• Collaborate with healthcare professionals to promote the appropriate use of medical center resources.
• Actively participate in Multidisciplinary/Patient Care Progression Rounds.
• Escalate cases to Physician Advisors and/or Care Management Director as per policy.
• Document in the medical record following regulatory and departmental guidelines.
• Take responsibility for ongoing professional development.
• Demonstrate excellent verbal and written communication skills, with the ability to engage with diverse populations.
• Exhibit critical and analytical thinking skills.
• Show proven clinical competency.
• Ability to multitask and perform in a fast-paced, high-pressure environment.
• Possess knowledge of discharge planning, utilization management, case management, and managed care reimbursement.
• Understand pre-acute and post-acute care levels and community resources.
• Work independently and exercise sound judgment in interactions with physicians, payors, patients, and families.
• Navigate the hospital environment effectively, ensuring presence in various areas as needed throughout the workday.
Qualifications:
A. Education/Skills
- Required education includes:
- Certificate, Associate, or Bachelor's degree in Nursing
- Bachelor's or Master's degree in Social Work
B. Experience
- Preferred experience in clinical or acute care settings.
C. Licenses, Registrations, or Certifications
- Required licensure includes LVN/LPN, RN, LBSW, LMSW, or LCSW in the state of employment.
- BLS certification preferred.
Work Schedule:
Varies
Work Type:
Per Diem As Needed
