Patient Care Coordinator (MSW)
The Patient Care Coordinator (MSW) is accountable for the administrative and clinical coordination and management of multidisciplinary care teams. The coordinator ensures that patient care's administrative and clinical aspects are consistently maintained at the highest home health standards, continuity of care, and service delivery are most efficient.
Essential Duties & Responsibilities:
Care Coordination and Scheduling:
- Acting as the administrative liaison between the agency, patients, caregivers, payers, and providers.
- Assisting in managing patient care and ensuring quality service and satisfaction.
- Working in partnership with administrative and clinical personnel throughout the agency.
- Monitoring the work of schedulers, field clinicians, and other administrative office personnel and assisting in working more effectively.
- Managing intake and referral processes, including insurance verification and authorization.
- Coordinating schedules for in-home visits by nurses, therapists, and other care providers.
- Maintaining accurate and up-to-date records in the EHR.
Patient and Family Communication:
- Acting as the primary point of contact for patients and families regarding care plans and service updates.
- Communicating with empathy and clarity, keeping family members informed about care plans, schedule changes, or new physician orders.
- Addressing the concerns/complaints of the patient, caregiver, client, provider, and other stakeholders, resolving the issues and escalating as needed.
Interdisciplinary Team Collaboration:
- Facilitating and participating in multidisciplinary case conference meetings with administrative and clinical personnel to coordinate the delivery of patient care.
Care Plan Management:
- Administratively partnering with admitting clinician and other administrative personnel to facilitate the completion of the plan of care (485) and other administrative paperwork for compliance.
- Maintaining and updating individualized care plans for each patient.
- Monitoring patients' progress and ensuring timely reassessment and care plan updates.
- Coordinating with the clinical team to adjust care plans or visit frequency as necessary.
- Ensuring services are delivered in accordance with the physician's orders and agency policy.
Patient Follow-Up:
- Conducting regular follow-ups with field clinicians through supervisory home visits to check patients' well-being and confirm that the care instructions are being followed.
- Conducting regular follow-up through phone calls to identify any new needs and service satisfaction.
Documentation and Records:
- Performing data entry, record keeping, correspondence, computer composition, technical drafting, and office work.
- Answering the phone, answering routine (non-clinical) administrative and clinical questions from patients, physicians, and providers reading information from an electronic health record (EHR).
- Maintaining confidentiality and safety of patient clinical records.
- Maintaining administrative compliance with the submission of all clinical orders, authorizations, visits, and other documents required by federal and state regulations.
Regulatory Compliance:
- Assisting the management team in administering, planning, and facilitating in-services.
- Assisting the management in compliance with the required documents required by the state and federal regulations.
- Assisting the management team in compliance with the Medicare/Medicaid requirements and HIPAA privacy rules.
- Complying with accepted professional standards and principles.
- Verifying that the care delivery matches the physician's orders and authorized frequencies.
- Assisting in managing compliance with the OASIS assessment transmittal to the federal government.
- Maintaining compliance with Medicare, Medicaid, and other payor requirements.
Quality Assurance:
- Participating in quality improvements and compliance activities.
- Conducting audits and reviewing patient charts for completeness.
- Working with the management team to develop better processes for care coordination.
- Assisting in identifying problems with performance and developing solutions to those problems.
- Providing input on improving patient satisfaction and outcomes based on feedback and observation.
- Initiating informal measures to correct performance issues for formal disciplinary actions to the management team.
- Recommending training needs to improve performance of the administrative and clinical team.
- Performing other administrative & clinical duties and activities as delegated.
Position Overview statements are only meant to summarize the major duties and responsibilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
Education / Licensure Requirements:
- Master of Social Work (MSW), completed
- Current certification in Basic Life Support (BLS) for Healthcare Providers, including CPR and AED
Qualifications & Skills:
- Preferred: Administrative experience in a pre-acute, acute, or post-acute setting leading and executing administrative functions.
- Required: Data entry, answering telephones, filing administrative & clinical records.
- Preferred: One (1) year of recent Home Health experience.
- Preferred: Management experience.
- Preferred: Sufficient background knowledge and expertise in administrative leadership, planning, and execution in support of clinical decision-making for the patient population assigned to him or her in the home health agency to meet the needs of his or her patients and to contribute to quality management review and evaluation.
- Sufficient computer skills to operate an Electronic Medical Record system.
- Sufficient knowledge of Medicare regulations is necessary to be knowledgeable and able to perform an OASIS assessment.