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| 10-00454 |
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| 3/18/2010 |
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Clinical Care Coordinator Summary:
The Clinical Care Coordinator comprehensively plans for Care Management of targeted patient populations. Performs resource management, including denial management, utilization management, access to the appropriate level of care, discharge planning, care facilitation, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes
Essential Duties and Responsibilities:
? Perform Utilization Management, and Quality Screening for assigned patients:
Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards to include Canopy Software and Interqual guidelines.
Initiate working DRG
Utilizes InterQual criteria to ensure appropriate level of care for inpatient status as well as screening for access via emergency room, UHA Clinics and MD offices.
Screening for appropriateness for admission to WVUH Skilled Nsg Unit.
Screening for appropriate authorization and level of care for admission to WVUH Ruby Same Day Surgery and IP Surgery suite.
Communicates with Resource Center to facilitate covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (ie. Peer to Peer) and follows up to resolve problems with payors as needed.
Educates hospital staff and physicians to the payor regulations to prevent medical necessity denials.
? Denial Management
Assists the payor specialists as needed in responding to concurrent reviews and providing information as necessary to avoid denials for patient admission.
Negotiates concurrent denials and communicates findings to Finance and Outcome Managers.
Applies appropriate utilization criteria to assist with providing information to ensure medical necessity of patient admissions to WVUH and CRH.
Responsible for appealing all concurrent and retrospective medical necessity and preauthorization denials issued by federal and commercial payors. Reviews billing edits related to medical necessity prior to write-off.
Plans appeal strategy and submits written appeal within the payors required
Appeal timeframe with assistance from Care Management Medical Director.
Ensures denial and appeals are tracked and trended and reports to Director Care Management.
Assists acute Clinical Care Coordinator with DC planning of patients as needed; can perform the role of the Clinical Care Coordinator as needed.
Responsible for completion of all clinical reviews for patients admitted and discharged over the weekend and for discharged patients in which payors required additional information.
? Coordinates/facilitates patient progression throughout the continuum:
Collaborates with all members of the Multidisciplinary Team to facilitate the Clinical Care Coordinator process for designated caseload. Monitors the patients progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
Addresses/resolves system problems impeding diagnostic or treatment progress with the observation population proactively identifies and resolves delays and obstacles to discharge
Manages all aspects of discharge planning for assigned patients
Meets directly with patient/family to assess needs and develop an individualized discharge plan in collaboration with physician
Coordinate with healthcare team to determine if patient education is completed before discharge.
Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and discharge plan changes.
Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation
Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
Refers cases and issues to appropriate personnel, ie. Medical Director, Outcome Manager or Director, in compliance with department procedures and follows up as indicated
Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues, involving Outcome Manager as necessary.
Refers appropriate cases for social work intervention based on dependent criteria
Initiates and facilities referrals through the Resource Center for home health care, hospice, medical equipment and supplies
Documents relevant discharge planning information in the medical record according to Department standards
Facilitates transfer to other facilities for targeted patient population
? Actively participates in clinical performance improvement and quality activities:
Uses data to drive decisions and plan/implement performance improvement strategies related to Clinical Care Coordinator for assigned patients, including fiscal, clinical and patient satisfaction data
Uses quality screens in Canopy to identify potential issues, ie. Avoidable days and readmissions
Collects delay for services and other data for specific performance and/or outcome indicators as determined by department
Participates in development, implementation, evaluation and revision of clinical pathways and other Clinical Care Coordinator tools and serves as a member of the clinical resource/team, including participation of staff interviews/screening for hire.
Educate the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles
Participate in the development of clinical pathways and educate the physicians on the process (omit)
Identifies at-risk populations using approved screening tool and follows established reporting procedures
Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas as viewed on Care Managements Dashboard
Performance Standard: Adheres to the established Performance Expectations for WVUH Employees in the areas of People, Service, Performance Improvement, and Shared Values & Culture. |
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Current West Virginia RN licensure (may not be waived)
Bachelors Degree in Nursing preferred
Prior case management experience preferred
3 years clinical experience in a hospital setting required |
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| CARE MANAGEMENT ^403 |
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| Day/Afternoon |
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| Part-time (20 to 40 hours) |
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| 24.16 |
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| No |
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| Looking for a challenge? If you are motivated, talented, and eager, there's a future for you at WVU Hospitals. We are looking for people with the desire to make a difference in healthcare. WVU Hospitals is a 531-bed teaching institution that includes Ruby Memorial Hospital, WVU Children's Hospital, Chestnut Ridge Center (behavioral medicine), the Jon Michael Moore Trauma Center, and Rosenbaum Family House. Our employees are our most valuable asset. We offer competitive pay and benefits because we want to attract and retain employees who will support our mission of high quality patient care. |
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| 20 |
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| None Specified |
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| Varies |
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To search for an open position, please go to http://wvuh.isg2.com |
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