Care Coordination Specialist

Kaweah Health•Visalia, CA

3d•$20 - $31•Onsite

About The Position

The Care Coordination Specialist works in collaboration with RN Case Management (CM) staff to gather clinical data to monitor quality and effectiveness of patient care. Acts as a liaison between RN CM and insurance companies by transmitting clinical data for review. Assists with planning and execution of safe discharge plan in a timely manner while working in collaboration with the multi-disciplinary team.

Requirements

Two years of college or equivalent training/experience in health-related field
Utilization review and/or coding experience
Must understand basic medical terminology.
Strong organizational and multitasking skills, with the ability to manage multiple patients and tasks simultaneously.
Excellent communication and interpersonal skills, with the ability to interact effectively with patients, families, and healthcare professionals.
Knowledge of discharge medication delivery processes and procedures, including coordination with the outpatient pharmacy and the patient and or family.
Ability to work collaboratively with interdisciplinary team members and healthcare professionals.
Strong computer skills, with proficiency in electronic medical record documentation preferred. Proficient in using Excel for documentation.

Responsibilities

Reviews and records utilization review data for assigned caseload in a manner to ensure all inpatient records are current.
Refers to Case Management team any variances that relate to concurrent review of the medical record. During chart review, is aware of criteria for quality variances. Complies with Kaweah Health Policy by reporting utilization variances to Case Management Committee and/or the P.I. department as indicated.
Reviews medical records for admission and continued stay utilizing InterQual Severity of Illness and Intensity of Services for appropriateness of the admission and continued stay. Must also review all cases transferred in and out of special/intensive care areas using specific criteria. Participants in Sub Committee reviews as designated.
Informs the Case Management Team and attending physician of any questionable or denied cases resulting from the review of the onsite Medi-Cal reviewer, CMRI or private insurance companies. Initiates further action by following guidelines set forth in the Hospital Case Management Plan.
Facilitates and coordinates placement of patients in appropriate long-term care facilities.
Facilitates arrangements for acute transfer to other acute facilities when indicated.
Assists case management team with discharge planning services that can include coordination of equipment, home care, home health, and transportation services.
Participates in Continuum of Care rounds.
Accumulates information on community resources and links patients, families and staff to appropriate services.
Answers the telephone, screens calls and takes messages as appropriate, per hospital protocol.
Responsible for all clerical aspects of utilization review including, but not limited to, processing of referrals, input of authorizations into the system, mailing of referrals and attendance at Case Management meetings.
Maintains & manages all health plan benefit databases in the system and updates as needed.
Transmission of insurance reviews (Initial & Concurrent).
Takes telephone requests for authorizations.
Completes retro reviews in a timely manner.
Documents authorizations in SoftMed and Invision.
Completes CCS and other referrals as indicated with appropriate documentation.
Communicates payer needs to Case Managers in a timely manner.
Generates reports that summarize referrals and authorization activity.
Coordinates the denial appeal process in conjunction with management/RN supervision, including but not limited to writing and/or calling appeals to private insurers and Medi-cal.
Coordinates the input of registrar data and provides assistance to the RN Admissions Coordinators in placement of patients and physician communication.
Cross-trains in various functions as designated by management including but not limited to acute care, surgery, transitional care, registration, mental health, and acute rehab coverage.
Responsible for all clerical aspects of utilization review including, but not limited to, processing of referrals and input of authorizations in the system.
Tracks documentation of face-to-face encounters and communicates with doctors to obtain signatures when needed.
Establishes the availability of funds for the services required.
Communicates with patient and appropriate administrative and patient accounting personnel throughout the process.
Communicates with unit staff, patient and case management concerning special wound supply needs/equipment of patient to be admitted to home health.
Maintains current authorizations for all insurance sources.
Maintains monthly statistics through referral log.
Assures all intake information is complete and accurate including patient information (phone number and address) physician information (name, address, phone and fax number) and insurance information.
Inputs all necessary data into the intake system accurately and timely.
Responsible for securing and documentation all insurance authorizations and reauthorizations on assigned cases working closely with agency case managers to assure all visits are authorized.
Performs a review on all completed admissions within five business days of receipt checking all areas outlined in the admission review process to assure complete and accurate information.
Notifies patient's PCP of home health referral prior to accepting referral to assure PCP is willing to follow and sign for home health services.
Works with the Discharge LVN to identify appropriate patients for the lounge, based on clinical criteria and capacity of the lounge.
Oversees the flow of patients through the discharge lounge (inbound and outbound) through coordination with the Registered Nurses or the Discharge LVN.
Coordinates patient pick up from the medical units, transports patients to and from the discharge lounge, to waiting vehicles, or assists patients to the restrooms as needed.
Responsible for data collection of patient information, arrival time to the lounge, duration of stay, and medication delivery from the outpatient pharmacy.
Assists with the coordination of medication delivery to the discharge lounge, including working with pharmacy and nursing staff to ensure timely and accurate delivery of medications.
Receives patients and orients them to facilities within the lounge such as reading materials, television, refreshments and exit and restroom locations.
Supports the care for patients; ensures safety of patients in the lounge and management of operation issues in the discharge lounge.
Collaborates with interdisciplinary team members to ensure effective communication and coordination of care for patients in the lounge, and follows up on the needs of the patients as instructed by Registered Nurses or Discharge LVN.
Communicates effectively with patients and families to ensure understanding and compliance with lounge policies and procedures, and to arrange pick up times.
Provides feedback to the Throughput Supervisors related to discharge lounge and medication delivery processes.
Serves as the primary point of contact for all incoming and outgoing transfer requests, direct admissions, physician admissions, and patient placement inquiries.
Collects comprehensive clinical, demographic, insurance, and financial information required to facilitate patient acceptance.
Verifies insurance eligibility and benefits for incoming transfers and direct admissions.
Obtains or coordinates prior authorizations and payer approvals when required.
Communicates with insurance companies regarding authorization status, level of care determinations, and medical necessity documentation.
Completes Medical Necessity Certification Statement for Ambulance Transport
Completes Transfer Summary, Physician Certification and Authorization, and Patient Transfer Request & Acknowledgement forms.
Collaborates with registration to create FIN for direct admissions.
Participates in training of all newly hired Care Coordination staff. Assists the employee in the function of the department.
Assists patients with information and review Advance Directives.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.
Performs other duties as assigned.