Reporting to the Manager of Care Coordination, and according to established policies, procedures, patient care standards, and clinical guidelines, the Care Coordinator has accountability for overall patient progression through the continuum of care. The Care Coordinator collaborates with other members of the multidisciplinary health care team to appropriately manage clinical resource utilization. The Care Coordinator assesses and manages patient care processes to include: utilization management of medical care needs, patient and family education, discharge planning and follow-up care, and patient financial needs. The Care Coordinator collaborates with community agencies regarding continuity of care and assures services are provided that are appropriate to the age and developmental status of patients and caregivers.
PRINCIPAL DUTIES & RESPONSIBILITIES :
1. Initiates discharge planning activities upon admission. Coordinates and monitors each patient’s discharge planning process through the hospitalization. Collaborates with the patient, family and community agencies to identify and secure the appropriate resources and post-discharge setting.
2. Coordinates and facilitates multidisciplinary staffing and patient/family meetings as required. Facilitates continuity of care throughout the patient’s hospitalization.
3. Provides financial information and resources to patients and families to assist them with meeting their obligations related to reimbursement for their healthcare.
4. Monitors patients’ clinical criteria for continued stay and uses that information to plan the timing of the discharge.
5. Coordinates the provision of information and referrals for patients and their families regarding the psychosocial aspects of patients’ adaptation to illness.
6. Participates in the establishment and maintenance of effective working relationships with appropriate community service organizations and public agencies. Remains current on available community resources.
7. Pro-actively collaborates with the patient, families and staff to identify potential issues and barriers to discharge. Works closely with the patient, family and staff to resolve those issues. Keeps the Director and/or Manager of Care Coordination apprised of potential barriers and resolution of issues.
8. Assures early identification of patient/family learning needs and timely initiation of patient education.
9. Works with staff to provide age-specific and developmentally appropriate care and services for all patient populations.
10. Ensures compliance with regulatory standards related to discharge planning which includes completion of discharge screening criteria and Important Message for Medicare as required.
11. Participates in quality improvement activities and promotes the delivery of quality patient care.
12. Supports the Mission and Vision of RML Specialty Hospital by demonstrating RML’s Core Values of Service, Teamwork, Accountability, Integrity, Respect and Stewardship (STAIRS) in all actions. Promotes a positive patient/customer experience by exemplifying the principles of the Language of Caring in all interactions with patients, families and coworkers.
13. Maintains fiscal accountability for areas of responsibility.
14. Participates in orientation of new employees.
15. Participates in educational programs for RML Specialty Hospital staff and students to enhance their understanding of the continuum of care, including the psychosocial aspects of patient care.
16. Participates in research activities related to case management or social work in health care.
Minimum Skills & Abilities
The analytical ability to assess patient/family needs and develop and execute individualized goals.
The interpersonal skills necessary to interact with patients, families, medical personnle , and other members of the health care team.
The ability to perform efficiently and effectively under the pressures of stressful or emergency situations.
The clinical and technical skills to work with technologically advanced equipment and computers.
The ability to direct and develop a multidisciplinary team approach to patient-centered care.
Minimum Knowledge & Experience
Completion of one of the following:
Graduate of an accredited school of nursing. Minimum of two years expereince in an acute care setting with medically complex adult patients. OR
Graduate of an accredited school of social work; minimum of two years experience as a social worker in an acute care setting working with medically complex adult patients. OR
Baccalaureate degree in a healthcare related field and a licensed health care provider. Minimum of two years experience in an acute care setting working with medically complex adult patients.
Demonstrated knowledge of relevant state, federal, and Joint Commission requirements.
Understanding of multidisciplinary approach to care coordination and quality improvement.
Preferred Knowledge & Experience
Baccalaureate nursing degree
Critical care experience preferred
One year experience in a case management, utilization management, discharge planning or other comparable role incorporating patient management across the continuum of care
License & Certifications
Illinois Registered Nurse License OR
Illinois Licensed Social Worker OR
Illinois licensed health care provider
Working Conditions
Work is performed in a patient care environment in the Chicago or Hinsdale campus . Requires frequent walking around the patient care units and the facility to attend meetings. Prolonged periods of sitting at the desk, computer work and reading can be anticipated.
The above statements are intended to describe the general nature and leve of the work being performed by people assigned to this job. They are not exhaustive lists of all duties, responsibilities, knowledge, skills ,abilities , and working conditions associated with it.
8/2017