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Care Coordination Specialist
2 months ago
Care Coordination Specialist (RN)
Luminis Health
Part Time - Day shift (M-F, 8a-4:30pm, 24 hrs/week, rotating weekends)
Position Overview:
The Care Coordination Specialist operates under the guidance of the clinical leadership in care management, ensuring effective care transitions for patients within Luminis Health. This role employs a collaborative methodology to identify, assess, plan, implement, and evaluate the necessary services and options to address an individual's health and related needs, taking into account social determinants that influence overall wellness. The specialist is responsible for connecting patients with appropriate resources at the right time and level of care, while also determining the correct initial and ongoing care levels based on evidence-based guidelines.
Key Responsibilities:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Identifies and prioritizes patients requiring care coordination services, employing a comprehensive approach that includes biopsychosocial, functional, cultural, spiritual, and financial considerations; collaborates with a multidisciplinary team to assess and plan for care needs.
2. Implements engagement strategies, such as motivational interviewing, to enhance patient involvement, self-management, adherence to treatment, and overall health optimization.
3. Utilizes evidence-based protocols (such as InterQual or other recognized guidelines) to ensure quality care, reduce variability, and minimize waste. Confirms appropriate care levels; documents actions to prevent denied days; refers cases to the Physician Advisor as necessary.
4. Proactively manages patients in observation status, ensuring timely diagnostics, treatment, and transition to inpatient care or discharge.
5. Develops and coordinates discharge plans for patients transitioning to home care, community support programs, hospice, palliative care, or other post-acute services; ensures all necessary documentation and handovers are completed. Prepares patients and families for transitions from various care settings as required.
6. Maintains thorough documentation in each patient record, reflecting physical and functional limitations, psychosocial aspects, educational needs of patients and families, and any financial or transition requirements. Initiates referrals to appropriate disciplines as needed.
7. Engages in nursing unit and departmental clinical outcome initiatives as well as process improvement projects related to care management.
8. Identifies patient situations that necessitate referral to other healthcare team members, such as infection control or quality management, ensuring that care plans are adjusted accordingly and follow-up is conducted. Keeps leadership informed of potential issues.
9. Employs risk and predictive analytics tools, such as readmission risk assessments, applying tailored interventions to address potential barriers, prevent unnecessary hospitalizations, and reduce readmission rates.
10. Ensures compliance with all regulatory standards (CMS, commercial insurers, etc.)
Qualifications:
BSN or ADN with equivalent experience. A BSN must be obtained within five years of starting in this role.
A minimum of three years of experience in a clinical environment, whether ambulatory or post-acute.
Experience in care coordination is preferred.
Licensure/Certification:
Current licensure as a registered nurse by the relevant state board of nursing.
Compliance with the credentialing requirements as outlined in the organizational bylaws.
Work Environment and Physical Demands:
There is a reasonable expectation that employees in this position may be exposed to blood-borne pathogens.
Physical Demands - Medium work
The physical demands and work environment described are representative of those encountered while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
This job description provides an overview of the functions and requirements for this position. It is not intended to be an exhaustive list of every duty and requirement; supervisors may assign additional responsibilities as necessary.
