Care Coordinator

3 weeks ago

Castro Valley, California, United States Talent Software Services Full time
Care Coordination and Transitions

At Talent Software Services, we are seeking a skilled Care Coordinator to join our team. As a Care Coordinator, you will play a critical role in ensuring the timely progression and transition of patients to the appropriate level of care. This position requires collaboration with the Physician, Utilization Manager, Medical Social Worker, and bedside RN to prevent unnecessary admissions or readmissions.

Key Responsibilities:
  • Review initial physician admission care plan.
  • Gather additional medical, psychosocial, and financial information from the patient/family interview, medical record assessment, physicians, and other healthcare providers.
  • Determine moderate or high risk level for readmission.
  • Conduct a screening for ancillary supportive services, including but not limited to Palliative Care Services' needs.
  • Functionally supervise and actively lead the healthcare team in developing comprehensive cost-effective care coordination plans that meet the clinical needs of our patients.
  • Identify and refer quality and risk management concerns to the appropriate level for patient safety reporting and trending.
  • Direct and oversee the Case Management Assistants to determine preferences for post-acute care services.
  • Utilization Management.
  • Review medical record to ensure patient continues to meet level of care (LOC) requirements and that chart documentation supports LOC determination and assignment.
  • Work with Attending Physicians to confirm necessary documentation to support level of care (LOC).
  • Expedites transition planning for patients who no longer require acute level of care.
  • Monitors length of stay (LOS) and outliers requiring additional resources and/or focus.
  • Collaborate with financial counselor for delivery of inpatient stay denials.
  • Ensure delivery of Medicare Important Message within 48 hours of discharge/transition and no less than 4 hours of actual discharge/transition.
  • Actively participates in patient rounds following the standard work as developed and collaborates with interdisciplinary team to assure timely transition.
  • Follows policies and procedures for Physician Advisor referrals.
  • Utilizes appropriate escalation process when discussing level of care (LOC) requirements with providers.
  • Consistently documents in the EHR and other electronic software.
  • Maintains current knowledge of CMS and Joint Commission Transitions of Care requirements, Conditions of Participation (COPs), and other regulatory requirements.
  • Effectively follows Observation patients, re-evaluates and collaborates with attending physician for admission or transition to appropriate level of care for the patient.
  • Care Coordination/Care Transitions.
  • Formulates a transition plan after reviewing available/appropriate care options and obtaining input, and collaborating with the patient/family and physician, healthcare team, payers, and community-based support services.
  • Performs, documents, and communicates assessment findings to healthcare team.
  • Screens 30-day readmissions; reviews previous hospital record confers patient/family and with interdisciplinary team to create an effective and realistic transition plan.
  • Proactively identifies barriers to care progression and transition, and works with multi-disciplinary team to resolve timely.
  • Addresses complex clinical and social situations efficiently in order to avoid unnecessary admissions, improper level of care utilization, and delays in transition.
  • Reviews and modifies plan of care.
  • Ensures timely transition to lower level of care.
  • Assesses the need for follow-up appointments and when applicable communicates to patient/family prior to transition.
  • Ensures necessary paperwork for post-acute transfers to comply with state and federal regulatory requirements.
  • Identifies ED high utilizers and makes appropriate care plans and referrals to community resources.
  • Identifies patient and families with complex psychosocial issues (social determinants of health) and refers to healthcare team as appropriate.
  • Communicates with Financial Counselors regarding uninsured, underinsured and makes referrals, as appropriate.
  • Makes appropriate and timely referrals and completes documentation to comply with state and federal regulatory requirements.
  • Identifies patients appropriate for case management intervention by reviewing the electronic health record (EHR) and meeting with patients and collaborating with staff and physicians.
  • Follows locally determined resources and workflows for patient transfers.
  • Actively participates in ongoing department operations.
  • Identifies new system, processes, protocols, and/or methods to improve practices.
  • Actively contributes to the creation of cost-effective practices that ensure the best patient/provider experience, effective resource utilization, and safe outcomes.
  • Effectively communicates with Care Management colleagues for safe transitions.
  • Actively aware and manages all communications (email, KDS, Policies & Procedures, Handoffs, and other) and participates in all department meetings.
  • Uses effective interpersonal and communication skills to promote customer service with internal and external customers.
  • Develops and maintains positive, productive, and professional relationships with the healthcare team and representatives of community agencies.
  • Relates with tact and respect to all customers with diverse cultural and socioeconomic backgrounds without personal judgment.
  • Be a positive participant, actively engaged in all department operations.
  • Willingly provides and accepts direct, constructive feedback to and from colleagues and the leadership team.
Certifications:
  • CA RN License
  • BLS
  • CUTE INPATIENT CASE MANAGER EXPERIENCE REQUIRED AS PER MANAGER
Weekend Requirements:
  • EOW

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