Clinical Care Coordinator

LifeBridge Health - Baltimore, MD3.7

Job Description:
Clinical Care Coordinator. Must have RN license and nursing experience. This role will support Women's and Children's Services at Sinai Hospital, including responsibilities for discharge planning and chart review.

The clinical care coordinator partners with the acute care medical providers to facilitate the progression of care for the hospitalized patient. Together with the medical provider, the clinical care coordinator collaborates with all members of the inter-disciplinary team including, but not limited to, nursing, specialty consultants, therapy, pharmacy, etc. with a focus on the delivery of efficient, high quality care. This position ensures appropriate utilization of clinical resources while driving toward a safe and timely discharge for the patient. This role will assist in the navigation of health system services to support
effective transitions while advising the team on healthcare industry compliance. The clinical care coordinator must be adept at driving throughput metrics, clinical effectiveness, and fiscal responsibility.


Clinical Effectiveness:
Clinical effectiveness requires the clinical care coordinator to collaborate with the health care team to develop the plan of care and patient flow. Reviews all cases within 24 -48 hours of admission from all points of entry and each day throughout the stay to facilitate care progression to establish an anticipated length of stay and transition planning needs. Collaborates with medical team to formulate a treatment plan to include transitions of care and promote patient flow. Completes an initial assessment in a timely manner for the purpose of identifying barriers that impact length of stay and discharge planning. The assessment should also identify the needs of the patients, acknowledge current resources available, and anticipate future resources needed to facilitate successful transitions. Navigates the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults and procedures are appropriately indicated and performed timely. Articulates the plan of care and communicates this plan when necessary to other care team members and patient/caregiver. Intervenes to maintain care progression when a deviation in plan occurs.

Promote Positive Outcomes:
Influences positive outcomes by communicating the plan of care, expected discharge date, and transition needs to the patient/caregiver and team thereby enhancing patient and staff satisfaction. Creates overall transitional and discharge plan of care based on initial assessment in collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family. Participate in daily interdisciplinary rounds incorporating evidence/best practice milestones incorporated in the plan and communicate that plan to the health care team. Apprises the interdisciplinary team of the estimated length of stay, barriers toward discharge, care progression barriers, anticipated disposition, and identifies needs from team to facilitate that plan, identifying opportunities for organizational improvement. Facilitate smooth transitions of care by insuring appropriate clinical follow up is arranged and referrals to proper post acute providers are initiated. Communicates the plan effectively with the patient and care gives making certain that they have resources for success post discharge.

Communication Skills:
Possess effective verbal and written communication, relationship building techniques and negotiation skills.Performs clear and concise documentation of the plan of care and can communicate this to the interdisciplinary team and the patient. Independently identifies and communicates any problems or issues that affect patient flow, patient satisfaction, patient safety, length of stay management, or outcomes to the department director and/or appropriate key stakeholder. Negotiate with the third party payer to obtain authorization for needed services. Functions as a resource for governmental and health care industry regulations and ensures compliance, communicates standards to the interdisciplinary team. Effectively keeps the patient and family informed of the plan of care and the progression for the plan, facilitates communication with the providers and encouraging open dialogue.

Performance Improvement:
Stays abreast of changing organizational, emergency department, Care Management, clinical trends, regulatory matters, and third party payer requirements related to clinical care, discharge planning, and pre-certification or aftercare benefits. Attends and contributes to departmental staff meetings. Participates and contributes to multi disciplinary committees and other committees or workgroups as directed. Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, readmissions and denials while suggesting strategies to improve organizational/departmental performance.


Basic professional knowledge, equivalent to a Bachelor's degree; working knowledge of theory and practice within the specialized field. ASN degree required; BSN preferred. 3-5 years of relevant RN nursing and/or care management experience. Maryland Registered Nurse License (RN) and American Heart Association CPR Cert. Intent to achieve MD licensure if out of state; Case management cert required within 3 years of hire.