Clinical Care Coordinator

Northwell Health

About The Position

Evaluates and assesses patients admitted to the Hospital. This role involves performing concurrent and retrospective reviews, determining appropriate alternate levels of care, and processing adverse determination decisions. The Clinical Care Coordinator identifies problematic care patterns, collaborates with physicians and other healthcare professionals, and implements discharge plans. They also act as a liaison with insurance carriers and arrange for post-hospital services. A key function is to perform clinical care coordination assessments within 72 hours of admission and ongoing reviews every 48 hours or as necessary, communicating with physicians to justify the severity of illness, intensity of service, and quality of patient care. The role requires staying updated on changes in Medicare/Medicaid/Commercial Insurances related to clinical documentation, utilization management, and case management processes.

Requirements

Graduate from an accredited School of Nursing.
Current license to practice as a Registered Professional Nurse in New York State.
Minimum of two (2) years medical/surgical experience in an acute-care hospital.

Nice To Haves

Bachelor's degree in nursing, preferred.
Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010, and obtain a BSN degree within five (5) years of employment date.
Experience in utilization management/discharge planning preferred.

Responsibilities

Performs concurrent review on all patients and shares problematic cases with the Supervisor and Physician Advisor.
Determines and makes appropriate referrals concerning alternate level of care.
Processes adverse determination decisions to Physician Advisor and distributes notification, as appropriate.
Identifies problematic care patterns or cases and makes referrals to the Supervisor and the department involved.
Performs retrospective reviews as required.
Participates in the maintenance of Utilization Management, Discharge Planning and Case Management statistics as required.
Keeps abreast of all changes in policies and procedures relating to Utilization Management, Discharge Planning and Case Management process.
Attends Utilization Management Committee and other staff meetings, as required.
Participates, as required, in ALC meetings.
Participates in Interdisciplinary Patient Care Rounds.
Identifies services or treatments that may not be medically necessary and makes referrals to the Physician Advisor.
Consults with physicians and other health care professionals on aspects of patient care.
Makes referrals to other hospital departments for collaboration and assistance in discharge planning.
Implements a discharge plan as necessary; documents ongoing discharge planning activities in the patient's medical record according to protocol.
Schedules family/patient conferences with the interdisciplinary team, as needed, to assist in coordinating a safe and timely discharge plan.
Collaborates with appropriate professional personnel to assess patients for alternative level of care and notify appropriate hospital departments.
Refers patients who require institutional placement to the Social Work Department for follow up and action.
Acts as a liaison with patient's insurance carrier (case manager, utilization reviewer) to coordinate post hospital services and referrals.
Makes arrangement for non-North Shore-Long Island Jewish Home Care services including home care, Hospice, equipment, supplies and laboratory services for post discharge needs.
Arranges for patient's post hospital needs, i.e. visiting nurse, physical therapy, medical/social model day care, personal care aides, Long Term Home Health Care Programs, home health aides, private hire, DME (equipment, supplies, and respiratory needs).
Assists in identifying patient incidents through the NYPORTS program.
Performs Clinical Care Coordination assessment within 72 hours of admission on all patients.
Perform ongoing reviews every 48 hours or as necessary.
Communicates with physicians to ascertain clarification of documentation to justify severity of illness, intensity of service and quality of patient care.
Keeps abreast of all changes in Medicare/Medicaid/Commercial Insurances as it relates to the clinical documentation process, the utilization management process and the case management process.
Shares all problematic cases with the Supervisor of CM-CCC.
Identifies problematic documentation patterns or cases and make referrals to the appropriate departments, to the Supervisor of CM-CCC and/or the Physician Advisor.
Performs any and all related duties as required.
Performs any and all related duties.