Care Management Coordinator

GENERAL SUMMARY:

Responsible for the overall coordination of the plan of care for all Merrick Medical Center (MMC) hospital patients with high-need chronic conditions. Within the hospital setting, this role proactively collaborates with an interdisciplinary team of providers, clinicians, and family/community/social resources to transition the patient through the appropriate levels of care, promote high quality outcomes and provide post-discharge support. Proactively collaborates with providers, clinicians, and family/community/social resources to improve patient experience, ensure high quality outcomes, and reduce unnecessary hospital utilization.

Responsible for educating patients on and encouraging patients to self-manage their specific chronic conditions. Serves as an expert in the areas of routine and complex diabetes education and self-management skills as it applies to patients with diabetes of all ages including specialized and/or risk assessment goal setting, determining and implementing evidence-based interventions, evaluations and outcome measurements.

PRINCIPAL JOB FUNCTIONS:

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Participates in meetings, committees and lean projects as assigned.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise while maintaining a state-of-the-art approach to diabetes care, self-management training and age specific education.
• Performs service excellence must-haves to achieve an excellent patient/customer experience.
• Uses quality improvement processes, programs or outcome to help improve department operations.
• Oversees formulation, execution and documentation of goals and objectives, plans and programs keeping in alignment with the overall Medical Center goals and objectives, plans and programs.
• Actively participates in organizational and departmental goals and action plans to achieve desired results.
• In the hospital setting, utilizes clinical skills to clinically manage and coordinate patient cases.
• Participates in multi-disciplinary rounds and collaborates with members of the interdisciplinary team to define and achieve patient and family goals.
• Collaborates with provider(s) in managing the patient’s length of stay or transfer.
• Facilitates patient/family participation in care planning, delivery and evaluation.
•  Assists Quality Coordinator in ensuring consistent clinical standards of care; identifies opportunities for quality improvement and best-practice efforts.
•  Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care.
• Implements patient and family education (group and individual) in all aspects of diabetes care, according to the 15 content areas of the national Standards for Diabetes Educations, and in conjunction with all American Diabetes Association (ADA) requirements for an ADA recognized program.
• Maintains MMC’s certification program with the ADA and oversees re-certification process.
•  Manages the flow of information to/from the providers and clinic office.
•  Maintains a chronic care management log according to regulatory guidelines.
• Performs Utilization Review functions such as coordination of patient services to meet applicable guidelines, regulations and admission criteria and coordinates swing bed admissions, discharges and transfers with medical staff, nursing, social service and transferring facility as needed.
•  Communicates regularly regarding plan of care for patients and any issues pertaining to level of care status.
• Ensures compliance with Federal, State and Local regulations regarding utilization of hospital services including ensuring patients are placed in the appropriate level of care according to clinical situation and prescribed plan of care and performing pre-screens for financial admits and transfers.
• Assists Social Worker with referrals and coordinates financial counseling for information and initiation of financial assistance forms when needed.
• Responsible for preparation and delivery of continued stay documents and denial information and administers and documents appropriate Hospital Issued Notices of Non-Coverage.
• Assists with community wellness including wellness connections and others as needed.
• Performs other related projects and duties as assigned.

EDUCATION AND EXPERIENCE:

Graduation from an accredited professional nursing program required. Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.