The Care Coordinator is a member of the multidisciplinary team that actively facilitates those functions that move a patient through an acute episode of care and links to internal and external resources and the payor community. The Care Coordinator assumes responsibility and leads the process which assesses, plans, implements, monitors, and measures the effectiveness of interventions to meet patients treatment and transitional needs. Requirements of the job may include cross coverage to utilization review/ care coordination. Cross coverage will include training to the new area and will give the employee additional knowledge and experience within the department. The employee will be proficient in both areas and will work in both areas as needed within budgeted hours.

Care Coordination/Transition Planning
* Proactively screen and assess the acuity and transitional needs of the patient.

* Partners 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.

* Encourages and facilitates patient and family participation in all care team decisions.

* Collaborates 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
* Assures post-acute plan is addressed in daily rounds, keeping patient and family in mind while modifying the plan when appropriate.

* Maintains appropriate and timely documentation to include specifics related to planning and coordination activities.

Insurance and Utilization Management
* Interfaces with Utilization review specialist to stay current on patients eligibility for admission, continuing stay, or readiness for discharge.

* Identify and record episodes of avoidable delays due to the failure of progression of care processes.

* Understands CMS requirements and Readmission penalties.
Leading Multidisciplinary Team
* Partners with the physician to organize the transitional plan for patient care.

* Collaboration with nursing and specialty disciplines to facilitate the transition to a lower level of care.

Resource Management
* Evaluates the appropriateness of care delivery in the inpatient setting and communicates any discrepancies with the medical team.

* Facilitates the management of care in an outpatient setting.

* Takes a leadership role in identifying opportunities to reduce risk both financial and clinical, through analysis and resources consumption outcomes.

* Assertively manage resource utilization while appropriately navigating patient movement along the continuum of care.

Compliance/Safety
* Stays current and complies with state and federal regulations/statutes and company policies that impact the employees area of responsibility.

* If required for position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job specific training in the specified time frame.

* Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

Education
Bachelor’s Degree- Required
OR
Master's of Social Work- Required

Master's Degree in Nursing- Preferred

Certification & Licensures
RN license in the State of Arizona- Required
OR
For applicants with Master's of Social Work degree, LMSW or LCSW- Preferred

Case Management Certification (ACMA, CMSA, CCMC)- Preferred

NAHMG Clinic-Based Staff and Outpatient Care Management:
Fingerprint Clearance Card application number- Required upon hire

Fingerprint Clearance Card- Required within 90 days of hire

Experience
1+ Years experience in healthcare- Preferred

Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.