The Clinical Care Coordinator works collaboratively with all members of the health care team and the participant/family to ensure coordination of participant care and resource utilization. Responsible for ensuring cost effective and quality participant care by appropriate utilization of contracted resources. Works under the direct and indirect supervision of the Executive Director or designee.
Care Management
1. Monitors care provided by inpatient providers to assure participant care conforms to accepted practice standards. This primary includes emergency room and inpatient medical and psychiatric admissions as well as LTAC and SNF stays.
2. Communicates with PACE team, caregivers and providers as well as contracted service providers to coordinate care, utilization and discharge planning while in a contracted facility.
3. Oversees discharge planning from facilities and assures that a plan is developed and implemented as participants transition back to the community.
4. Reviews emergency room and inpatient records and works with case managers, discharge planners and social workers to review utilization and care needs during hospitalization.
5. Provides daily and as needed updates to the PACE IDT and providers on participants who are hospitalized.
6. Completes the daily tracker for all PACE sites and distributes daily
Leadership
1. Demonstrates active participation in Quality Assurance Performance Improvement processes.
2. Conforms to regulatory, customer and organizational requirements.
3. Oversees utilization quality plans as designated on the annual quality plan
4. Complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective participant care management, resolves issue/problem and completes written reports.
5. Maintains relationships with case managers and discharge planners and provides education on PACE services and regulatory requirements.
Interdisciplinary Team
1. Works with team and the participant/family in developing or revising the plan of care; makes referrals to interdisciplinary support services at time of discharge from a contracted facility
2. Records participant updates and discharge planning in the EMR.
Education: Bachelor's degree (RN Degree, occupational therapy, physical therapy or social work.)
Experience: 3 years clinical experience and 1 year working with frail/elderly patients.
Licensure/Certification: Active Unrestricted Clinical license required in the state of hire for RN, PT or OT.
