Job Description Proactively assist the Care Transition Manager with providing information to the patient regarding the transition of care. Develop relationships to facilitate discharge planning and continuum of care needs. Perform duties to avoid readmissions and ER visits to the hospital. Analyze and trend data to improve overall utilization metrics.
Job Responsibilities Educate the patient about what to expect, review criteria to determine benefit structure, authorize and approve benefits as medically necessary.
Engage the patient and caregivers upon admission to the hospital and throughout the hospital stay, discharge instructions, transition preparedness, follow-up appointments, and care, using teach-back methodology to assure the patient understands the treatment plan and is well prepared for transition to the next level of care; in coordination with the Care Transition Manager.
Assist the unit nurse and Care Transition Manager with medication reconciliation at admission and near the time of discharge, ensuring medications are appropriate for outpatient continuation considering formulary and affordability.
Notify the Primary Care Physician (PCP) of the patient’s hospital admission and facilitate conversations between the hospital team and the PCP. Collaborate with the interdisciplinary team to ensure the plan of care is understood and documented. Participate in rounds with physicians, case managers, and social workers as needed. Ensure discharge documents are delivered to the PCP and to Hill Physicians care management. Work with the onsite Case Manager and Hill Concurrent Review nurse to plan post-discharge services as far in advance as possible.
Ensure tests, consultations, imaging studies, treatments, and procedures are performed timely and identify and address any barriers to care progression. Contact doctors or care team members as needed to move care forward.
Arrange PCP follow-up appointment as soon as possible after admission (and with specialists as needed) for a visit within no more than 10 days after discharge. Ensure appointment time is known by the patient, unit nurse, and documented on the discharge document, including arrangements for home health, home infusion, durable medical equipment, skilled nursing, and rehabilitation. The Transition Care Coordinator collaborates with the interdisciplinary team to implement the discharge plan.
Refer patients to Hill Physician Case Management for post-discharge “Welcome Home” program.
In collaboration with the CTM and team:
Provide resource information and referrals.
Interpret and coordinate health plan benefit coverage with the member’s healthcare needs.
Refer patients to Health Education and Health Plan Disease Management programs as appropriate.
Coordinate all services and interventions with all participating providers and the member through effective and timely communications.
Negotiate for out-of-benefit or out-of-network services and for cost-effective healthcare utilization.
In collaboration with the CTM and team:
Measure outcomes to determine if quality and cost effectiveness of case management is met, including outcomes data such as member surveys, quality of life, clinical and financial data.
Participate in Quality Improvement activities by analyzing quality data and recommending opportunities for improvement.
Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
Coordinate internal and external resources for the individual member.
Utilize existing reports and systems to identify and monitor utilization resource patterns and facilitate needed care coordination to support Quality Improvement.
Refer to Hill Concurrent Review Supervisor for supportive interventions as needed (e.g., Health Education, Quality Management).
Ensure patients whose surgeon desires co-management are seen by the consultant or hospitalist.
If determined beneficial, arrange a home-visit by a physician.
If requested by ACO leadership or supervisor, extend visits to a skilled nursing facility or rehabilitation facility.
Attend ACO, Hospital, and Health Plan meetings as needed.
Drive or travel daily for work-related duties as required.
Other duties as assigned.
Required Experience 3-5 years of related managed care experience required.
Representative of HPMG at onsite facilities with ability to coordinate effectively with members, providers, hospital and office staff, health plans, internal departments, community resources, and peers.
Ability to work effectively with physicians, hospital and office staff, and members; able to work independently or in a team; strong multitasking and critical thinking skills.
Excellent organizational and communication skills; able to meet timeframes.
Computer literate in routine applications (Word, Excel) and internet resources.
Strong ability to analyze and trend utilization management data and develop process improvement plans.
Experience with CPT/ICD9 codes preferred.
Required Education High School Diploma/GED required.
Medical Assistant Certificate preferred.
Additional Information Salary: $30 - $33 hourly
Hill Physicians is an Equal Opportunity Employer