The Care Coordinator is a member of the multidisciplinary team that facilitates patient progression through an acute episode of care and links to internal and external resources and the payor community. The Care Coordinator leads the process which assesses, plans, implements, monitors, and measures the effectiveness of interventions to meet patients\' treatment and transitional needs. Cross coverage to utilization review/care coordination may be required, including training in the new area and working in both areas within budgeted hours.
Responsibilities Care Coordination/Transition Planning
Proactively screen and assess the acuity and transitional needs of the patient.
Partner with the Interdisciplinary team to facilitate placement in a rehab, SNF, sub-acute, assisted living facility, or home with Home Health Care, as well as arrange DME and other services as ordered.
Identify appropriate consultative services that would enhance patients\' timely transitional plan.
Encourage and facilitate patient and family participation in all care team decisions.
Collaborate with post-acute services, care managers, and PCPs to ensure transition back to the home environment.
Clinical Knowledge Understands basic medical terminology and conditions for hospital treatment.
Understands consultative disciplines and the role they play in patient care.
Communication and Documentation Ensure post-acute plan is addressed in daily rounds, keeping patient and family in mind while modifying the plan when appropriate.
Maintain appropriate and timely documentation to include specifics related to planning and coordination activities.
Insurance and Utilization Management Interface with Utilization review specialist to stay current on patient eligibility for admission, continuing stay, or readiness for discharge.
Identify and record episodes of avoidable delays due to failure of progression of care processes.
Understand CMS requirements and Readmission penalties.
Leading Multidisciplinary Team Partner with the physician to organize the transitional plan for patient care.
Collaborate with nursing and specialty disciplines to facilitate the transition to a lower level of care.
Resource Management Evaluate the appropriateness of care delivery in the inpatient setting and communicate any discrepancies with the medical team.
Facilitate the management of care in an outpatient setting.
Identify opportunities to reduce financial and clinical risk through analysis and resource consumption outcomes.
Compliance/Safety Stay current and comply with state and federal regulations/statutes and company policies that impact the employee\'s area of responsibility.
If required for the position, ensure all certifications and/or licenses are up-to-date and valid prior to expiration dates.
Complete all company mandatory modules and required job-specific training in the specified time frame.
Report any safety-related incident in a timely fashion through the Midas/RDE tool; attend safety-related training; perform work safely; monitor the work environment for potential safety issues and ensure others are also performing work safely.
Qualifications Education Bachelor\'s Degree - Required
OR Master\'s of Social Work - Required
Master\'s Degree in Nursing - Preferred
Certification & Licensure RN license in the state of Arizona - Required
For applicants with Master\'s of Social Work degree, LMSW or LCSW - Preferred
Case Management Certification (ACMA, CMSA, CCMC) - Preferred
Fingerprint Clearance Card application number - Required upon hire
Fingerprint Clearance Card - Required within 90 days of hire
Experience 1+ years experience in healthcare - Preferred
Note: This description reflects the responsibilities, qualifications, and expectations for the Care Coordinator role and does not include external job postings or referral prompts.