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Clinical Care Coordinator
2 months ago
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 stakeholders to ensure timely and accurate information exchange.
- Assign appropriate levels of care and complete 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.
- Monitor Length of Stay (LOS) and ancillary resource use on an ongoing basis, taking actions to achieve continuous improvement in both areas.
- Refer cases and issues to the Care Management Medical Director in compliance with Department procedures and follow up as indicated.
- Communicate with the Resource Center to facilitate covered day reimbursement certification for assigned patients.
- Discuss payor criteria and issues on a case-by-case basis with clinical staff and follow up to resolve problems with payors as needed.
- Use quality screens to identify potential issues and forward information to the Clinical Quality Review Department.
- Ensure that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
- 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 the 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.
- Refer appropriate cases for social work intervention based on Department criteria.
- Collaborate/communicate with external case managers.
- Initiate and facilitate 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.
- Facilitate transfer to other facilities as appropriate.
- Actively participate in clinical performance improvement activities.
- Assist 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.
- Use 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.
- Document key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning).
- Use pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
- Lead the development, implementation, evaluation, and revision of clinical pathways and other Case Management tools as a member of the clinical resource/team.
- Assist in the compilation of physician profile data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction, and quality indicators (e.g., readmission rates, unplanned return to OR, etc.).
- Act as a preceptor/mentor to new hires.
- Assist in the development of orientation schedules and help identify individual needs for learning.
- Ensure safe care to patients, staff, and visitors; adhere 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; support department-based goals which contribute to the success of the organization; serve 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. Model Memorial Hermann's service standards by providing safe, caring, personalized, and efficient experiences to patients and colleagues.
