Care Coordination Specialist

Kaweah Health•Visalia, CA

1d•$20 - $31

About The Position

The Care Coordination Specialist collaborates with RN Case Management staff to gather clinical data and monitor the quality and effectiveness of patient care. The role acts as a liaison between RN Case Management and insurance companies by transmitting clinical data for review, and assists the multidisciplinary team with timely, safe discharge planning and execution. Depending on the assigned department or function, the position may support insurance utilization review, home health intake and authorization processes, discharge lounge operations, or patient intake and transfer coordination. The role also supports newly hired Care Coordination staff, assists patients with information about Advance Directives, and performs other assigned duties.

Requirements

Two years of college or equivalent training or experience in a health-related field.
Utilization review and/or coding experience.
Understanding of basic medical terminology.
Strong organizational and multitasking skills, including the ability to manage multiple patients and tasks simultaneously.
Excellent communication and interpersonal skills 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.

Nice To Haves

Proficiency in electronic medical record documentation.
Proficiency in using Excel for documentation.

Responsibilities

Review and record utilization review data for assigned caseloads, keeping inpatient records current.
Refer concurrent-review variances to the Case Management team, identify quality variances, and report utilization variances in accordance with hospital policy.
Review medical records for admission and continued-stay appropriateness using InterQual Severity of Illness and Intensity of Services criteria, including reviews of transfers into and out of special or intensive care areas.
Inform the Case Management team and attending physician of questionable or denied cases resulting from reviews by onsite Medi-Cal reviewers, CMRI, or private insurers, and initiate follow-up under the Hospital Case Management Plan.
Facilitate placement in appropriate long-term care facilities and acute transfers to other facilities when indicated.
Assist with discharge planning, including coordination of equipment, home care, home health, and transportation services.
Participate in Continuum of Care rounds; gather information on community resources and connect patients, families, and staff with appropriate services.
Answer and screen telephone calls and take messages according to hospital protocol.
For insurance specialist duties, process referrals and authorizations, maintain health plan benefit databases, transmit initial and concurrent insurance reviews, complete retro reviews, document authorizations, prepare referrals, communicate payer needs, generate activity reports, and coordinate denial appeals.
For home health duties, process referrals and authorizations, track face-to-face encounter documentation, coordinate required signatures, verify funding availability, communicate with patients and staff, maintain authorization and referral records, enter intake data accurately, review completed admissions, and notify the patient's PCP of referrals.
For discharge lounge duties, identify appropriate patients with the Discharge LVN, coordinate patient flow and transportation, collect patient and lounge data, coordinate medication delivery with pharmacy and nursing staff, orient patients to the lounge, support patient safety, communicate with patients and families, and provide process feedback to Throughput Supervisors.
For intake coordinator duties, manage transfer requests, direct and physician admissions, and placement inquiries; collect clinical, demographic, insurance, and financial information; verify insurance benefits; coordinate authorizations; communicate with insurers; complete required transport and transfer forms; and collaborate with registration to create FINs for direct admissions.
Participate in training newly hired Care Coordination staff and assist them with departmental functions.
Assist patients with information and review of Advance Directives.
Provide care and services appropriate to the population served in the assigned unit or work area, and perform other duties as assigned.