GENERAL SUMMARY/ OVERVIEW STATEMENT:
The RN Care Coordinator (RNCC) manages a caseload of patients and is responsible for ensuring care that supports desired clinical and financial outcomes. Has the skills and knowledge specific to the unique needs of assigned patients. Coordinating the care prescribed by an interdisciplinary team, the RNCC utilizes patient assessment, care guidelines, protocols, payer regulations and response to therapies to assess the episode of illness from pre admission to post discharge. Participates in the ongoing evaluation of practice patterns and systems and supports efforts to improve quality, cost and satisfaction outcomes. Mobilizes resources to maximize efficiency of care delivery.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
A. Care Facilitation
Coordinates and insures implementation of the plan of care, utilizing case management principles.
Prior to or within 24-48 hours of admission the RNCC, by interview of the patient/family, discussion with physician team and/or attending MD and other team members, develops a provisional treatment program and tentative discharge date.
Reviews daily treatment plan with physicians, nurses and patient / families to insure interdisciplinary communication and coordination is occurring.
Participates with nursing staff and physicians in patient care rounds to contribute to plan of care and monitor and report patient progress.
Collaborates with other departments to expedite sequencing and scheduling of interventions, consults, treatments and ancillary services.
Provides for daily continuity with patients to assure patient needs related to discharge are met.
Incorporates knowledge of utilization management principles and payer contracts into patient plans of care. Keeps physicians and nurses informed of implications.
Presents alternatives to inpatient stay to attending MD, team and patient / family based on assessed patient level of care and insurance benefits
Seeks assistance and/or consultation from Care Coordination leadership with plans for outlier and potential or actual resource intensive patients.
Interacts with internal and external health care providers to facilitate patient care including post discharge services
Contributes to the development, implementation and monitoring of practice guidelines.
Identifies attending, resident and nurse learning needs related to case management and works with service leaders to develop educational plan.
B. Discharge Planning
Coordinates and executes the discharge planning process for patients, ensuring each patient has a discharge plan.
Assesses continuing care needs in conjunction with other caregivers.
Coordinates and schedules interdisciplinary meetings with the patient and family regarding discharge needs and plan as appropriate.
Assures patient education consistent with discharge plan has occurred.
Identifies service, treatment and funding options for post-hospital care.
Promotes interdisciplinary patient/family communications and documentation that facilitate discharge planning striving to finalize plans the day prior to discharge.
Performs patient/family follow-up after discharge to monitor and support desired outcomes.
Initiates contact with home health agencies and extended care facilities to insure prompt and effective transition of care.
C. Utilization Management
Collaborates with appropriate individuals, departments, and payers to insure appropriateness of admission, continued days of stay, and reimbursement.
Identifies patients who are likely to have unmet insurance and resource needs and communicates with and/or makes referrals to other members of the health care team and other appropriate departments.
Communicates as needed with third party payers regarding patient's progress with treatment plan.
Identifies need for and issues Medicare notices of non-coverage, providing appropriate documentation of the process and communication to patient/family and other members of the health care team
Utilizing industry accepted utilization and/or medical management criteria (InterQual) identifies, monitors and reports variances from established treatment plan, including appropriateness of admission, continued stay, delays in treatment, and discharge plan.
Conducts documented utilization reviews to insurers or intermediaries.
Identifies SNF and AND days for Medicare and Medicaid patients.
Initiates actions concurrently to reduce and/or eliminate inappropriate hospital admissions and days, and system delays.
Works with payers and physicians to concurrently address level of care concerns effecting claims and reimbursement.
Contributes to utilization and practice improvement efforts by reviewing reports with colleagues and providing feedback on utilization trends and payer issues.
Serves as the primary patient information source to third party payers.
Education: Graduate of an approved school of nursing with current registration in Massachusetts. For newly licensed nurses a Bachelor of Science Degree in Nursing is required.
Two years of experience with discharge planning, knowledge of community resources and patient education principles required as a case manager.
Knowledge and skills to differentiate levels of care required.
Five years of previous acute care experience in related clinical specialty preferred.
Two or more years experience with hospital utilization review and medical criteria sets preferred.
Certification in case management preferred.
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
Previous experience in a hospital or health care setting
Bilingual (English/Spanish) preferred
Strong clinical assessment skills
Excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and with internal and external customers
Strong organizational skill and ability to set priorities
Ability to compile data from concurrent and retrospective medical record review to determine clinical appropriateness, able to demonstrate the ability to meet a patient's needs based on their clinical diagnosis, level of care and discharge plan
Ability to negotiate several aspects of care coordination simultaneously; excellent written and verbal communication skills
Works in a busy and at times stressful hospital and office environment. Must be flexible and able to work well independently
Brigham And Women's Hospital