RN Care Coordinator-Continuity of Care As-needed

Job Description

The RN Care Coordinator reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The RN Care Coordinator role works collaboratively with the physician and interdisciplinary team to: facilitate patient care, enhance quality of clinical outcomes and patient satisfaction, integrate and coordinate utilization management and proactive care progression, manage the cost of care and provide timely and accurate information to payers. This individual demonstrates professionalism while working collaboratively with physicians, the interdisciplinary team, and payers to ensure that patients receive the appropriate level of care and services to meet their ongoing healthcare needs in the most appropriate and cost effective environment possible. This role serves as a patient advocate in all situations.

Responsibilities:

Correctly apply approved medical screening  criteria to monitor appropriateness of admissions and continued stays, and document findings in Midas

Ensure status order is appropriate with patient’s initial presentation and ongoing stay, and accurately reflected in the computer for billing purposes (e.g. type of status, date and time per order). 

Pursue changes in status when indicated by medical screening criteria, physician advisor recommendation, or payer request.

Identify, refer and follow up with appropriate patients to physician advisor in a timely manner.

Clearly document appropriate clinical information in Midas to reflect medical necessity and progression.  Include patient’s clinical condition, current diagnoses, initial status order and changes, test results, plan of care, response to treatment, payer information, and follow up needed.

Identify appropriate anticipated discharge dates in collaboration with physician(s) and social service/discharge planners.

Communicate proactively and diligently with payers to provide clinical information to substantiate medical necessity for stay, and communicate with physician when additional information is needed.  Respond to all payer review requests within 24 hours of the request.

Communicate with patient/family regarding payer issues and concerns, delivery of observation brochures, and timely delivery of Medicare Important Message letters.

Provide education to physicians and staff on utilization management issues and criteria; act as resource. 

Refer cases/issues when appropriate and follow up is indicated to Case Management (CM) Director or Supervisor.

Identify appropriate Medicaid patients needing medical review and follow up.

Identify outliers and take appropriate action to progress care.

Identify avoidable days or delays, prevent when possible by communicating with physicians/staff/appropriate director, and document avoidable days in Midas. Refer to CM Director or Supervisor if further follow up is indicated.

Work collaboratively as a member of the health care team and patient/family/significant other to develop a plan of continuing care compatible with patient needs and financial resources while giving consideration to the normal characteristics of growth and development throughout the life span.

Assertively and actively collaborate with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management.  Monitor the patient’s progress, and intervene as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.  Seek consultation from appropriate disciplines/departments as required to assist with patient flow through the continuum of care.  Seek opportunities to progress patient’s care. 

Collaborate with the multidisciplinary team to eliminate barriers to efficient delivery of care in the appropriate setting.  Address/resolve system problems impeding diagnostic or treatment progress.  Proactively identify and resolve delays and obstacles to discharge.

Identify patients who will benefit from inclusion in Multidisciplinary Rounds.  Facilitate outcome-oriented Multidisciplinary Rounds. 

Initiate informal and formal care conferences as indicated and document appropriately.

Utilize conflict resolution skills as necessary to ensure timely resolution of issues.

Document care progression issues and positive impacts appropriately in Midas and in the patient record when appropriate.

Identify patient continuum of care needs and communicate with Social Services and appropriate members of the multidisciplinary team.

Identify barriers to discharge and communicate with Social Services.

Refer appropriate cases for Social Services intervention based upon established high-risk screening criteria.

Collaborate with  social services on a daily basis to address:Discharge plan and anticipated discharge date

Important Message receipt

Potential changes in discharge needs

Assist in progression to other facilities by obtaining pre-authorization and identification of network providers as indicated.

Consistently works with medical staff in an assertive, professional, proactive, collaborative manner.

Assist physicians with Utilization Management related activities.  Act as a resource to physicians.

Arrange services with consideration given to normal characteristics of growth and development throughout the life span.

Infants/Toddlers/Preschoolers - Involves parents & guardians in planning discharge needs & services for their children; advocates for child in arranging discharge planning needs.

School Age/Adolescents - Involves parents & guardians in planning discharge needs & services for their children; allows patient to have control/choices in discharge planning needs when possible.

Young Adults - Supports & provides information to persons making health-care decisions for themselves, their children, or for aging parents; allows to maintain control in decision making when possible.

Middle Adults - Allows expressions of concern regarding future health-care needs; recognizes physical, mental, and social abilities/needs of patients; provides hopeful attitude with focus on strengths; allowing to maintain control in decision making when possible.

Older Adults - Recognizes physical, mental, and social abilities/needs of patients; encourages acceptance of aging and loss of health/functioning; provides resources as needed to allow for independence & maintain dignity; works with children to make decisions for elderly parents; allowing to maintain control in decision making when possible.

Adults Age 80 and Older - Recognizes physical, mental and social abilities/needs of patients; encourages independence; allowing to maintain control in decision making when possible; supports end of life decisions – provides information/resources.

Promote positive relations with continuum of care providers including but not limited to medical staff, payers, patients/families, healthcare team, and all other customers.

Demonstrate initiative and participation with department routine chart review for quality criteria and/or as requested by Director or Supervisor.

Precept/mentor new department staff/students.  Help to identify individual needs for learning.

Actively participate in department and organizational performance improvement activities.  Offer suggestions for improvement, ideas to address problem prone issues.

Provide patient/family education based on assessment of learning needs, abilities, preferences, and readiness.

Demonstrate understanding of, and accountability for, responsibilities of department, including office duties.  Actively seek out additional responsibilities, assist peers as needed.

Act as resource to patients, community, and interdisciplinary team for advance directives.

Participate in hospital/system wide/community committees/teams as requested.  Communicate information to peers.

All other duties as assigned.

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