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Patient Care Coordinator
2 months ago
The Patient Care Coordinator plays a crucial role in managing all facets of a patient's hospital stay through activities related to their clinical treatment journey, resource allocation, quality enhancement, and discharge planning. This role involves conducting utilization assessments, reviewing patient records, and collaborating with various insurance providers to ensure proper payment and reimbursement.
Key Responsibilities
- Evaluate patient documentation and take ownership of admission and ongoing reviews to prevent denials from insurance providers. Facilitate notifications, submit clinical data, and liaise with payers for service approvals within specified timelines.
- Assess hospital medical records against established care protocols and communicate with multidisciplinary team members regarding expected length of stay, variances, discharge readiness, and optimal recovery benchmarks.
- Assist in utilization review by monitoring, documenting, and reporting on appeals at all levels, including peer-to-peer reviews and reconsiderations.
- Engage with attending and emergency department physicians regarding bed availability and care level criteria. Refer ambiguous cases to a Physician Advisor for further evaluation, following up as necessary.
- Coordinate the delivery of regulatory documents and communicate with discharge planners as needed regarding any changes in bed status.
- Investigate clinical records, relevant insurance and governmental regulations, accreditation standards, and claim history to determine the next steps.
- Ensure that collaborative planning processes are optimized and informed decisions are made from a patient-centered, strengths-based perspective; in partnership with the patient, family, and healthcare team, assess and evaluate medical, rehabilitative, psychosocial, and physical needs to implement appropriate discharge plans.
- Reassess and evaluate the suitability of the care plan, monitor progress towards goals, and ensure timely implementation of the plan. Keep team members informed of the current patient status and post-discharge care planning.
- Review the care plan and expectations with the patient, family, physician, and healthcare team members. Assist patients in navigating potential challenges related to the healthcare system, including financial or social barriers.
- Discuss all aspects of care planning with cultural sensitivity and awareness.
- Coordinate with all agencies involved in the patient's pre-hospital care and those planning for post-hospital care, including home health services, skilled nursing facilities, long-term acute care hospitals, and durable medical equipment providers.
- Provide necessary information to facilitate referrals, share pertinent details to support transitions of care, schedule post-discharge primary care appointments, and follow up with high-risk patients post-discharge to ensure the plan is executed as intended, intervening when necessary.
- Act as a contact, advocate, and informational resource for patients and their families. Serve as a patient and family advocate by empowering patients to achieve autonomy and self-determination in reaching their goals. This includes education on advance directives, patient rights, and responsibilities.
- Assist patients in articulating their preferences and priorities regarding discharge.
- Perform other duties as assigned.
- Minimum: Associate Degree in Nursing (ASN) or Bachelor’s Degree in Social Work.
- Preferred: Bachelor of Science in Nursing (BSN) or Master of Social Work (MSW).
- Minimum: Two (2) years of experience in utilization review and discharge planning.
- Preferred: Five (5) years of experience in utilization review and discharge planning.
- Minimum: Registered Nurse, Licensed Social Worker, Clinical Social Worker, or LMSW as appropriate based on educational background.
