Additional Information
Provides department support for the Case Management team to facilitate discharge planning and ensure appropriate throughput. Works with Case Managers and Case Management Assistants to ensure discharge plans are communicated to patients and families and enables a positive patient experience with discharge process. Follows up post discharge with patients to ensure arranged post acute services are provided as ordered and patients are satisfied with discharge process and with agencies providing the services.
Under the supervision of the ambulatory care manager, the care coordinator provides care coordination services required to meet an individual's health care needs to promote cost-effective, quality outcomes. Assists members of the health care team in the management of specific patient populations in the inpatient and outpatient settings. The care coordinator role assists the ambulatory care manager with the functions of complex case management, utilization management, quality management, discharge planning, and Transitions of Care (TOC) with the coordination of post-hospital care services, including transfers to an alternative level of care.
Essential Duties:
Clinical Care Coordination 1. Works with the ambulatory care management nurse to manage a case load. supporting up to 200 commercial outpatients. 2. Contributes to the Transitions of Care (TOC) process, with coordination of post-acute services for specific populations in the outpatient setting. 3. Collects data from multiple sources and works with the ambulatory care management nurse to assess patient needs. 4. Collects data in collaboration with patient, family, physician, health care team and works with the ambulatory care management nurse to develop a plan of care. 5. Collaborates with the ambulatory care management nurse to ensure a specific plan of care is in place for all patients. Assist the ambulatory care management nurse to the timely completion of all delegated assigned tasks, from the associated plan of care. Provide coordination of care such as schedule members' appointments; arrange transportation, etc. as outlined in policy and procedures. 6. Actively participates in interdisciplinary meetings and team huddles. 7. Answer phone calls from providers, facilities, or patients, related to the status and processing of requests received from ambulatory care management nurse. 8. Assists with data collection for ongoing discharge planning needs, documents changes in computer system under the direction of the ambulatory care management nurse. 9. Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met. 10. Demonstrates collaborative working relationship with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff.
Patient Education 1. Assist health care team with identification of patient/family educational needs for discharge. 2. Inform patient/family of discharge plan and involve them in decision making regarding care. 3. Work with Transitions of Care process, to deliver post-acute services to address educational needs to ensure a safe discharge plan. 4. Work with patient/family to learn Self-Management methods for on-going monitoring and treatment of chronic conditions.
Resource Management 1. Proposes alternative treatment options to ensure a cost effective and efficient plan of care. 2. Identifies and creates solutions to remove barriers that may impede optimal patient care. 3. Complete case management care plans, including delegated tasks and interventions, that effectively prevent ER Visits, Hospital admissions, or Re-admissions. 4. Works with ambulatory care management nurse to ensure (InterQual or MCG) concurrent reviews are completed upon hospital admission and every two days. 5. Participates in InterQual and/or MCG competency testing. 6. Completes assignments timely and communicates to appropriate care team members. 7. Able to prioritize tasks, assignments, and duties under the direction of the ambulatory care management nurse. 8. Notifies ambulatory care management nurse timely when unable to complete assigned tasks, or for the escalation of clinical issues or support. 9. Assists ambulatory care management nurse with duties and/or tasks as assigned.
Perform other duties as assigned.
Required Qualifications:
Req High school or equivalent
Req 3 years Clinical experience.
Req Experience with computer data entry
Req Typing 40-55 WPM
Req Good organizational skills
Req Good customer service skills
University Of Southern California · Los Angeles