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Clinical Care Coordinator (Call-In)

Company

REHAB Hospital of the Pacific
Address , Honolulu, 96817, Hi
Employment type PART_TIME
Salary
Expires 2023-08-01
Posted at 11 months ago
Job Description
Position Title: Clinical Care Coordinator
FLSA Status: Exempt
Reports To: Care Coordination Manager
POSITION SUMMARY:
The Clinical Care Coordinator is responsible for coordinating the delivery of care throughout the REHAB continuum of care for the assigned patient population. Functions include case management, utilization management, quality data capture, timely discharge planning and ongoing coordination of care needs.
The Clinical Care Coordinator works closely with the multidisciplinary team to actively facilitate those functions associated with moving the patient through an acute episode of care, providing linkages to internal resources, community resources, other healthcare providers, patient’s family and caregivers, and the payer community. The Clinical Care Coordinator collaborates as needed to facilitate the transition of inpatients to the outpatient clinics, including working with referral sources and outside case managers in the management of patient care through the continuum.

ESSENTIAL FUNCTIONS:

CORE VALUES

Models REHAB’s core values, HEART, in daily actions. Honesty – Speak and act with truth and respect. Engagement – Embrace and commit to our mission, vision and values. Aloha – Serve others with a spirit of kindness and compassion. Resilience – Rebound and recover with a sense of urgency. Teamwork – Work together for success.
TRANSITION PLANNING
  • Initiates and collaborates with payer representatives, REHAB’s Patient Financial Services (PFS) department and other areas to verify a patient’s financial status and insurance coverage.
  • Communicates with patients, families and caregivers to ensure understanding of payer guidelines and to arrange referrals to other health care providers.
  • Has primary responsibility for managing care transition of patients accepted for REHAB admission from acute care hospitals, home, or other facility or level of care, in cooperation with the Community Liaisons and the Care Coordination Manager.
  • Identifies patients in need of post-discharge care equipment and/or services, as well as assisting in such planning of services.
  • Acts as a resource and monitors emerging issues with discharge medications.
  • Communicates with patients, families and caregivers, physicians, multidisciplinary team members and payers to facilitate coordination of clinical activities and discharge planning, and to enhance the effect of a seamless transition from one level of care to another across the continuum of care.
  • Convenes, participates and conducts interdisciplinary conferences to solicit input from clinical and administrative team members on patients.
  • Collaborates with team members to develop a transition plan appropriate to the patient's physical, cognitive and financial needs.
  • Assists in making referrals to clinical psychology when a patient or family needs psychosocial intervention to facilitate transition planning.
  • Serves as consultant and educator to the patient, caregivers and family regarding post-discharge service recommendations.
  • Communicates patient needs to appropriate professional (i.e. clinical psychologist, clinical pharmacist, clinical dietician) and follow-ups on communication.
  • Determines patient's potential need and initiates assessment of eligibility for post-discharge services within 72 hours of inpatient admission.
  • Serves as liaison to community resources.
  • Communicates with clinical and administrative staff to ensure compliance with applicable clinical and financial guidelines.
  • Communicates with payer representatives to advocate for the patient’s inpatient and post-discharge care needs; provides representatives with documentation to justify services/equipment to meet those needs.
  • Understands the diversity of customer needs, and demonstrates the knowledge and skills necessary to provide services to the customer (i.e. stands in front of a geriatric individual and speaks slowly and distinctly, allows individual with a disability enough time to complete tasks, etc.).
  • Assists in scheduling and follow-up on medical and therapeutic appointments.
CLINICAL MANAGEMENT
  • Establishes lines of communication with community liaisons, nursing, therapy, PFS and support service managers.
  • Participates in the development, implementation, evaluation and ongoing revision of the plan of care, clinical pathways and initiatives to improve quality, continuity and cost effectiveness.
  • Facilitates referrals to the appropriate areas to expedite care, treatment, equipment acquisition and services.
  • Attends patient rounds and participates in setting priorities of patient needs.
  • Works collaboratively with other Clinical Care Coordinators to ensure timely and complete coverage of all care coordination needs at REHAB.
  • Confirms doctor's treatment plan and intended goals.
  • Monitors the patient's progress toward the desired outcomes.
  • Has knowledge of and acts in accordance with laws and policies and procedures regarding patient confidentiality.
  • Secures clinical resources essential to achieve the desired outcomes.
  • Collaborates with physicians, patients and families and nurses to identify probable post-discharge care needs and providers of service.
  • Collaborates with attending physician to establish treatment milestones to prepare patient and family for discharge from acute inpatient rehabilitation.
MEDICAL DOCUMENTATION
  • Collaborates with compliance director, payers and Health Information Management staff to be knowledgeable regarding documentation.
  • Shares written information with physicians to inform and educate on the dimensions of payer-related matters and accurate documentation.
  • Actively collaborates with physicians to ensure accurate and comprehensive documentation.
PROCESS AND PERFORMANCE IMPROVEMENT
  • Participates in process improvement projects.
  • Works collaboratively with other departments and services to define and study areas of inefficiency.
  • Is involved in developing strategies and plans to maximize the most appropriate use of services in assigned areas and resources in the community.
RESOURCE MANAGEMENT
  • Identifies trends/problems related to delivery of care, delays and potentially avoidable days through consistent and timely monitoring and data capture.
  • On a concurrent basis, assesses the appropriateness and timeliness of the level of care, quality and clinical risk issues and completeness of documentation.
  • Applies severity of illness/intensity of service criteria for patients admitted to REHAB or extending their stay.
  • Intervenes with ancillary department leadership and external service providers when timely service is critical to the patient's immediate needs.
  • Reviews the ordering of diagnostic testing and outside clinical procedures, alerting treatment team to possible coverage and utilization management issues
  • Assists in monitoring quality review studies and trends occurring with denials; keeps abreast of changes in insurance and payer requirements, including worker’s comp.
  • Interacts with the clinical staff, patients, patient families, caregivers and physicians to explore the most appropriate setting to meet the patient needs.
PROFESSIONALISM
  • Observes and follows house rules and dress code.
  • Keeps self updated on hospital and unit announcements, including updated policies and procedures.
  • Supports and promotes REHAB’s mission, as a positive role model, demonstrating a proactive approach to situations, and practicing REHAB values.
  • Demonstrates competence with technical skill review of procedures, treatments, and equipment usage.
  • Completes assignments within scheduled work hours.
  • Interacts openly and professionally while supporting management directives and strategic objectives.
  • Complies with and updates yearly skills review per policy and timely completes requirements needed to maintain position and/or employment at REHAB.
  • Accountable to start and end work based on designated work shift. Demonstrates flexibility with work schedule as needed. When appropriate, obtains approval from the supervisor for changes and/or variances.
  • Incorporates professionalism and demonstrates customer service in the daily delivery of care through positive communication and positive interpersonal relationship with internal and external customers.
  • Demonstrates commitment to quality services.
  • Offers recommendations to improve processes and/or operations of the department.
  • Attends and participates in inservices, conferences and educational programs to assure continued professional growth and maintains unit education record.
  • Respects patient’s rights and preferences.
  • Maintains confidentiality of information during and related to the course of work and performance of duties.
  • Participate in continuous improvement projects.
COMPLIANCE
  • Participates in REHAB initiatives to improve processes and communication
  • Promotes and adheres to REHAB’s Compliance Program.
  • Establishes and keeps current policies and procedures.
  • Identifies, recommends and implements solutions to issues.
  • Assures that all department and hospital policies are followed.
OTHER FUNCTIONS:
  • Performs other duties as assigned.

SCOPE OF PRACTICE:

The population served includes individuals affected by stroke, orthopedic related conditions, brain and spinal cord injury, amputation, major multiple trauma, and other neurological and medical conditions. REHAB’s patients range from pre-teen to geriatric age ranges.
JOB SPECIFICATIONS:

REQUIRED QUALIFICATIONS
Certification/Licensure:
  • Current BLS certification
  • Current State of Hawaii RN or LSW licensure.
  • Completion of competencies and other job-related and REHAB requirements.
Education:
  • Graduate from a school of Nursing or Master’s degree in Social Work.
Skills/Experience:
  • Requisite clinical knowledge to enter into a partnership with key stakeholders.
  • One (1) year of healthcare experience.
  • Ability to influence action. "Care" to advocate for change, collaborate with and complement the clinical members of the patient’s healthcare team.
  • Knowledge of community resources.
  • Ability to negotiate with interdisciplinary team members, physicians, families, payer sources and peers.
  • Knowledge of evolving healthcare systems, including but not limited to funding sources, third party reimbursement, Centers for Medicare and Medicaid Services, contractual arrangements, managed care, continuum of care issues, disease management and clinical guidelines.
  • Effective written and verbal communication skills.
  • Experience with using personal computers.
  • Effective interpersonal skills with positive relationship building.
PREFERRED QUALIFICATIONS
Certification/Licensure:
  • Certified Case Manager
Education:
  • Bachelor’s degree in Nursing or equivalent experience as an RN.
Skills/Experience:
  • One (1) year of case management experience.
  • Two (2) years of healthcare experience.
EQUIPMENT, TOOLS, WORK AIDS USED
Office supplies and equipment, including telephone, computer and multifunction devices (MFDs). Google’s G Suite, report writer and database software.