Care Coordination Specialist

Kaweah Health•Visalia, CA

2d•$20 - $31

About The Position

The Care Coordination Specialist works in collaboration with RN Case Management staff to gather clinical data and monitor the quality and effectiveness of patient care. The role serves as a liaison between RN Case Management and insurance companies by transmitting clinical data for review. It also assists with timely, safe discharge planning in collaboration with the multidisciplinary team. The position is in the Home Health Agency department and is full-time, benefit-eligible, with a day shift of eight hours or less. Responsibilities vary by assigned function and may include utilization review, insurance authorization and referral processing, home health intake coordination, discharge lounge operations, and coordination of patient transfers and admissions. The specialist reviews clinical records and authorization documentation, communicates with payers and care teams, coordinates appropriate placements and services, and helps ensure complete and timely records and patient transitions. Additional duties include training newly hired Care Coordination staff, assisting patients with information about Advance Directives, and performing 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.
Proficiency in Excel for documentation.

Nice To Haves

Proficiency in electronic medical record documentation is preferred.

Responsibilities

Review and record utilization review data for an assigned caseload, keeping inpatient records current.
Refer variances identified during concurrent medical record review to the Case Management team and report utilization variances as required by policy.
Review medical records for admission and continued-stay appropriateness using InterQual Severity of Illness and Intensity of Services criteria, including specified transfers to and from special or intensive care areas.
Participate in designated Sub Committee reviews.
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 further action under the Hospital Case Management Plan.
Facilitate placement in appropriate long-term care facilities and arrange acute transfers to other facilities when indicated.
Assist the case management team with discharge planning, including coordination of equipment, home care, home health, and transportation services.
Participate in Continuum of Care rounds.
Gather information about community resources and connect patients, families, and staff with appropriate services.
Answer and screen telephone calls and take messages according to hospital protocol.
Process utilization review referrals and authorizations, transmit initial and concurrent insurance reviews, take authorization requests, and complete retroactive reviews in a timely manner.
Maintain health plan benefit databases and document authorizations in SoftMed and Invision.
Complete CCS and other referrals with appropriate documentation, communicate payer needs to Case Managers, and generate reports summarizing referral and authorization activity.
Coordinate denial appeals with management or RN supervision, including writing or calling private insurers and Medi-Cal.
Coordinate registrar data entry and assist RN Admissions Coordinators with patient placement and physician communication.
Cross-train in designated functions, which may include acute care, surgery, transitional care, registration, mental health, and acute rehabilitation coverage.
For Home Health, process referrals and authorizations, generate activity reports, track face-to-face encounter documentation, and contact physicians for signatures when needed.
For Home Health, establish funding availability, communicate with patients and administrative and patient accounting personnel, and coordinate special wound supply or equipment needs.
For Home Health, maintain current insurance authorizations, monthly referral-log statistics, and accurate, complete intake information and system entries.
For Home Health, secure and document authorizations and reauthorizations for assigned cases, working with agency case managers to ensure visits are authorized.
For Home Health, review completed admissions within five business days of receipt and notify the patient's PCP of the referral before accepting it to confirm the PCP will follow and sign for services.
For the Discharge Lounge, work with the Discharge LVN to identify appropriate patients based on clinical criteria and lounge capacity, and coordinate patient flow with nurses or the Discharge LVN.
For the Discharge Lounge, coordinate patient pickup from medical units, transport patients to and from the lounge and waiting vehicles, and assist patients to restrooms as needed.
For the Discharge Lounge, collect patient and lounge timing data, including medication delivery information, and coordinate medication delivery with pharmacy and nursing staff.
For the Discharge Lounge, orient patients to lounge facilities, support patient safety and operational needs, and follow up on patient needs as directed by nurses or the Discharge LVN.
For the Discharge Lounge, communicate lounge policies and pickup arrangements to patients and families and provide feedback to Throughput Supervisors about lounge and medication delivery processes.
For Intake Coordinator duties, serve as the primary contact for transfer requests, direct and physician admissions, and patient placement inquiries.
For Intake Coordinator duties, collect clinical, demographic, insurance, and financial information; verify insurance eligibility and benefits; and obtain or coordinate prior authorizations and payer approvals.
For Intake Coordinator duties, communicate with insurers about authorization status, level-of-care decisions, and medical necessity documentation.
For Intake Coordinator duties, complete the Medical Necessity Certification Statement for Ambulance Transport, transfer and physician certification forms, and Patient Transfer Request & Acknowledgement forms.
For Intake Coordinator duties, collaborate with registration to create a FIN for direct admissions.
Participate in training newly hired Care Coordination staff and assist employees with departmental functions.
Assist patients with information about and review of Advance Directives.
Provide care and services appropriate to the population served in the assigned unit or work area.
Perform other duties as assigned.