The care coordinator assumes responsibility and accountability for the collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to ensure quality, cost-effective outcomes. Closely monitors length of stay for all assigned patients.
Education
Bachelor's Degree in Nursing - Preferred or Master's Degree in Social Work - Preferred.
Experience
1-2 Years of nursing or social work experience - Required.
3 - 5 Years of case management experience in acute care setting - Preferred.
License & Certification
Professional License with State of Practice - Required for Nurse; Preferred for Social Worker.
National Certification in Case Management - Preferred.
Core Job Functions
Performs brief assessment, readmission risk assessment, and 6 clicks mobility assessment within one business day of admission.
Discuss discharge-planning needs with patient, family, and care team to determine the most effective coordination of resources.
Ensures patient/family/caregiver is aware of and agreeable to expected day of discharge.
Reassess and document updates to discharge plan every 2 days including patient understanding or refusal of plan.
Collaborates with Social Workers for complex-patient problem resolution.
Resolves outstanding or unanticipated discharge issues through communication with patient, family, and care team.
Schedules regular family conferences to maintain communication.
Presents and discusses high-risk complex patients at high risk LOS / Complex Care rounds with CCC leadership.
Discusses barriers with the attending physician and if unsuccessful, escalates to leadership and Physician Advisor.
Attends MDRs per department standard operating procedure.
Provides GMLOS, actual LOS, and expected date of discharge for every patient each day.
Focuses MDR team’s attention on identifying barriers to discharge and creating a plan of action to address the barriers.
Provides insights on appropriate patient status and level of care.
Reviews action items created during MDRs at the daily 2pm touchpoint meetings to determine resolution versus need for additional action.
Identifies patients who are readmissions or at high risk of extending their stay beyond the GMLOS and takes actions to minimize avoidable days.
Documents avoidable days per department standard operating procedure.
Proactively interacts with Utilization Management team and attending physicians to review admission status and prevent inpatient denials.
Prioritizes review of SDC and Observation patients to determine if ready for discharge.
Follows payer requirements and government regulations to ensure compliant, safe, and cost-effective care.
Maintains communication with care team by checking voice mail and email at minimum every 2 hours.
Completes required documentation by the end of the workday.
Adheres to on-call schedule and works holidays/covers weekend WOW absences as scheduled.
Provides handoffs by email to team members as patients transition through the continuum of care.
Provides weekend / on-call / PTO handoff.
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