Position Objective: The care coordinator works under the direction of the clinical director of care management, providing coordination of care for patients at Luminis Health to support safe, seamless, timely transitions across the continuum. Utilizing a collaborative process, the care coordinator will identify (using quantitative and qualitative methods), assess, plan, implement and evaluate the options and services required to meet an individual’s health and health related needs, including social- determinants that affect ones’ overall wellbeing. The care coordinator promotes the right resources, at the right time and at the right level of care and is responsible for engaging and supporting patients that are in need of care management services.
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Identifies and prioritizes patient in need of care management services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors. Plans with the patient, family, other caregivers, primary provider and other members of the healthcare team to maximize health care responses, quality, and cost-effective outcomes.
- Identifies and implements strategies such as motivational interviewing to promote patient engagement, self-care, treatment adherence, and optimal levels of health and well-being. Facilitates inclusion of the patient in ongoing decisions regarding the plan of care supporting individualized care planning. Provides or facilitates education necessary to support timely and informed decisions and adherence to the plan of care.
- Utilizes evidenced based guidelines (such as InterQual or other agreed upon evidenced based guidelines) to promote quality care, decrease variation and mitigate waste. Verifies patient’s needs for acute level of care, collaborating with utilization management nurse to prevent potential denials. Tracks avoidable days in Epic. The care coordinator will address when patient is not receiving evidenced based care, and escalate to care management leaders and/or physician advisor if indicated.
- Manages observation stay patients assertively and ensures timely testing and treatment. Prioritizes this population. Ensures patients are converted when appropriate-guided by physician. Adheres to payer regulations such as the 2mn rule-CMS, addressing patient status prior to the second midnight with the physician. Arranges for continued ambulatory follow-up as indicated.
- Develops and coordinates transition plans for patients transitioned to home with home health, community care coordination program, Hospice or Palliative care, home infusion and routine sub-acute and skilled post-acute providers; completes all necessary documentation and necessary handovers.
- Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient & family, family/social support systems, financial, economic, and transition needs. Initiates referrals to disciplines as indicated.
- Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.
- Identifies potential or current patient situations which require referral to other members of the health care team such as infection control, risk management, or quality management. Assures plan of care is adjusted as appropriate and that follow-up occurs. Keep leadership abreast of potential issues.
- Utilizes all risk stratification and other predictive analytic tools such as the readmission risk tool and Epic LOS prediction tool. Applies tailored interventions to mitigate potential barriers or risk, prolonged unnecessary hospitalization and readmission prevention.
- Maintains compliance with all regulatory standards (CMS, commercial insurers, etc)
Educational/Experience Requirements:
Bachelor's degree in nursing required.
Three years of experience in a clinical setting, ambulatory or post-acute setting.
Care coordination experience is preferred.
Licensure/Certifications:
Current licensure as a registered nurse by the Maryland Board of Nursing.
Working Conditions, Equipment, Physical Demands:
There is reasonable expectation that employees in this position will be exposed to blood-borne pathogens.
Physical Demands – Medium work
The physical demands and work environment that have been described are representative of those an employee encounters 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.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
