Clinical Care Coordinator

1 week ago

Palo Alto, California, United States Memorial Hermann Health System Full time
Job Summary

The Memorial Hermann Health System is seeking a skilled Clinical Care Coordinator to join our team. As a key member of our interdisciplinary care team, you will play a vital role in ensuring the highest quality patient care and outcomes.

Key Responsibilities:
  • Coordinate and facilitate patient care progression throughout the continuum, working collaboratively with physicians, nursing staff, and other members of the multidisciplinary care team.
  • Monitor patient progress, intervening as necessary to ensure that the plan of care and services provided are patient-focused, high-quality, efficient, and cost-effective.
  • Facilitate the completion of diagnostic testing, treatment plans, and discharge plans, modifying the plan of care as necessary to meet the ongoing needs of the patient.
  • Communicate with third-party payors and other relevant information to the care team, ensuring timely and accurate information exchange.
  • Assign appropriate levels of care, completing all required documentation in TQ screens and patient records.
  • Collaborate with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
  • Complete Utilization Management and Quality Screening for assigned patients, applying approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays.
  • Identify at-risk populations using approved screening tools and follow established reporting procedures, monitoring LOS and ancillary resource use on an ongoing basis.
  • Take actions to achieve continuous improvement in both areas, referring cases and issues to the Care Management Medical Director as necessary.
  • Communicate with Resource Center to facilitate covered day reimbursement certification for assigned patients, discussing payor criteria and issues on a case-by-case basis with clinical staff.
  • Use quality screens to identify potential issues and forward information to the Clinical Quality Review Department, ensuring that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team.
  • Manage all aspects of discharge planning for assigned patients, meeting directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with physician.
  • Collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
  • Ensure/maintain plan consensus from patient/family, physician, and payor, referring appropriate cases for social work intervention based on Department criteria.
  • Collaborate/communicate with external case managers, initiating and facilitating referrals through the Resource Center for home health care, hospice, medical equipment, and supplies.
  • Document relevant discharge planning information in the medical record according to Department standards, facilitating transfer to other facilities as appropriate.
  • Actively participate in clinical performance improvement activities, assisting in the collection and reporting of financial indicators, including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
  • Use data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical, and patient satisfaction data.
  • Collect, analyze, and address variances from the plan of care/care path with physician and/or other members of the healthcare team, using concurrent variance data to drive practice changes and positively impact outcomes.
  • Collect delay and other data for specific performance and/or outcome indicators as determined by the Director of Outcomes Management, documenting key clinical path variances and outcomes which relate to areas of direct responsibility.
  • Use pathway data in collaboration with other disciplines to ensure effective patient management concurrently, leading the development, implementation, evaluation, and revision of clinical pathways and other Case Management tools as a member of the clinical resource/team.
  • Assist in compilation of physician profile data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction, and quality indicators, acting as a preceptor/mentor to new hires.
  • Ensure safe care to patients, staff, and visitors, adhering to all Memorial Hermann policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity, and quality of service.
  • Promote individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency, supporting department-based goals which contribute to the success of the organization, serving as a preceptor, mentor, and resource to less experienced staff.
  • Demonstrate commitment to caring for every member of our community by creating compassionate and personalized experiences, modeling Memorial Hermann's service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.

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