Care Coordinator (LCSW, LMSW or RN) FT Days

## Description JOB PURPOSE & MISSION The care coordinator position encompasses the process of case management practice in partnership with the medical staff and members of the clinical team accountable for outcomes of selected patient populations. The care coordinator is accountable to the patient and the community and is responsible for facilitating the patient’s safe, cost efficient, progression-of-care throughout the entire episode of acute care and assuring the patient’s timely and seamless transition back to the community. Essential Job Functions include, but are not limited to: 1. Facilitates triple aim initiatives by ensuring access to appropriate care. - Advocate for patients by assessing that patient healthcare needs are being addressed in the most appropriate level of care. - Understands and works in all hospital settings for patient coordination or care, such as the emergency department, ICU, Burn unit, Women & Infant, med/surg/telemetry, etc. - Screens patients to determine appropriate level of care coordination interventions based on risk factors related to barriers that impact progression of care, transition of care, and readmissions. - Assesses patient situation by collecting information from patient and family, professional and non-professional caregivers, employers (as appropriate), and health records to identify individual needs to develop a comprehensive progression-of-care management plan and assessment that will address those needs. - Confirms admission diagnosis and identifies related quality metrics to promote medical compliance. - Partners with the medical team to participate in developing a medical treatment plan appropriate to the patient’s level of care and preferences. - Encourages and facilitates patient/family participation in all care and treatment decisions. - Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care. - Recognizes and responds appropriately to risk factors. 2. Implements a wholistic and patient-driven approach to care management. - Assess the effectiveness of services and their outcomes in concert with the interdisciplinary team, recommending appropriate plan modifications to ensure treatment objectives are met. - Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care. - Provide point-of-care coaching to medical documentation that accurately reflects intensity of services, quality and safety indicators, and patients’ response to treatment. - Consults with medical advisors as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels. - Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, external case managers, and post-acute providers. - Facilitate and coordinate patent and family meetings to discuss goals of care, difficult treatment recommendations, new diagnosis, etc. - Facilitate complex psychosocial assessments and brief counseling on such topics as fetal demise, teen pregnancy, new cancer diagnosis, complex medical treatment needs, wound/burn care, trauma, guardianship, return to home barriers, goals of care, advanced directives, etc. as they impact patients’ hospitalization. 3. Orchestrates the coordination of care throughout the patient continuum. - Serve as a primary liaison between and among physicians, patients, families, payers, external case managers, post-acute providers, and interdisciplinary clinical team. - Maintain appropriate documentation for each patient to include specific documentation of all planning, liaison, and coordination activities. - Collaborates with post-acute coordinators to monitor and facilitate the progress of completing discharge logistics. - Proactively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason…