Care Transitions Coordinator - Population Health

WVU Medicine

About The Position

The Care Transitions Coordinator is responsible for coordinating and facilitating patient discharge planning during hospitalization, ED visits and transitions to and from skilled nursing facilities, long term acute care, and rehab facilities. The Coordinator works alongside physicians, nurses and social workers and other disciplines within the care team, including outside agencies, to expedite the appropriateness, effectiveness and timeliness of care. Candidate applies clinical expertise and medical appropriateness criteria to resource utilization and discharge planning, and manages the resources necessary for cost effective, quality patient care. This position includes meeting the needs and providing services to all age groups-infancy through geriatrics.

Requirements

Associate’s Degree in Nursing AND Five (5) years clinical experience in a healthcare setting OR Bachelor’s Degree in Nursing AND Three (3) years clinical experience in a healthcare setting.
Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Obtain certification in Basic Life Support within 30 days of hire date.
Working Knowledge of InterQual and/or Milliman Care Guidelines
Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning
Excellent written and oral communication
Problem solving capabilities to drive improved efficiencies and customer satisfaction
Attention to detail
Proficiency with Microsoft Office

Nice To Haves

Bachelor's Degree in Nursing.
Medical Management for Medicare and/or Medicaid populations.
Prior care coordination experience.

Responsibilities

Ability to interact with clinical departments as necessary to clarify components of the treatment or discharge plan.
Assesses, facilitates, and monitors the plan of care in conjunction with the patient and/or family/significant other.
Conducts concurrent chart review of selected patient populations, assesses the appropriateness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues, and completeness of medical record documentation.
Identifies and follows currently admitted and discharged patients in the Hospital, SNF, LTACH, or Rehab setting through a 14 day discharge period to facilitate a smooth and safe transition for the patient.
Evaluates patient needs/requests during needed transitions of care
Identifies issues/problems and makes appropriate recommendations. Communicates with patients, families/ significant others, medical staff, caregivers
Serves as a facilitator/advocate for patients and families in the resolution of problems related to the established plan of care and procurement of services.
Participates in Peak Health UM meetings, when applicable, to identify patient discharge needs prior to discharge to create a smooth transition for the patient.
Works with the Peak Health case management team, when applicable, to identify barriers and help facilitate any discharge referrals as needed including, but not limited to: Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.
Utilizes care planning screens, when available, in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions
Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to departmental policy
Refer patients, as needed, for continued case management into population health programs or other community resources as needed.