We are currently seeking a Care Coordinator to join the team at Nuvance Health in Danbury, CT!
Nuvance Health is a family of award-winning nonprofit hospitals and healthcare professionals in the Hudson Valley and western Connecticut. Nuvance Health combines highly skilled physicians, state-of-the-art facilities and technology, and compassionate caregivers dedicated to providing quality care across a variety of clinical areas, including Cardiovascular, Neurosciences, Oncology, Orthopedics, and Primary Care.
Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.
Performs assessments and formulates discharge/transition plans in collaboration with patient, family and multidisciplinary healthcare team. Provides ongoing monitoring and evaluation of plans to meet the individual needs of patients throughout the care continuum. Assists in resource management through facilitation of care and participation in program planning, data collection and analysis. Provides education to patients/families regarding coverage, care options and community resources.
- Care Coordination/Facilitation and Transition Management - coordinates multiple aspects of care to all appropriate patients to ensure the patient progresses through the hospitalization. Makes the transition to the next level of care with the services required to promote high-quality outcomes.
- Assists in the development of the patient's plan of care and ensures the plan is implemented timely. Discusses with the healthcare team identified delays while providing direction, assistance and support in developing strategies and interventions to move patient through the continuum of care. Follow up on any delays and help expedite diagnostics and treatments.
- Assesses patient's clinical readiness for transition in collaboration with the healthcare team and informs the team of the available resources based on the patient's clinical needs. Initiate paperwork to transfer information to the community providers timely. Maintains easy flow of communication regarding patient's development and progress to all involved in care of patient.
- Participates in the development and improvement of clinical initiatives focused on reducing LOS, Denials, Re-admissions and ensuring appropriate levels of care. Actively involved in all daily, weekly rounds/meetings. Knowledge of hospital and community resources and is a resource for the healthcare team.
- Maintains effective relationships and a positive outlook when interfacing with other departments, multidisciplinary healthcare team as well as patient's/families and community providers.
- Acts as an intermediary between patients, physicians and community providing advocacy, accurate healthcare information, potential referral services and proper treatment plans. Initiates and coordinates patient care conferences as required.
- Provides clinical social work interventions which include counseling, bereavement and crisis intervention as well as assessment and intervention in cases involving complex family/patient dynamics.
- Care Coordinators in utilization review audits all admissions and continued stays for assigned group of patients to determine certification to the assigned level of care utilizing standardized criteria to achieve optimal outcomes and reimbursements. Provides timely clinical information to the commercial insurers. Coordinates direct communication between MD's and insurers to proactively avoid denials. Identifies variances, avoidable days, readmission and LOS issues and works with department leadership and the healthcare team to develop changes in process to improve outcomes. Collaborates with other members of care coordination to communicates changes in level of care as well as other pertinent information required for an optimal transition plan. Provides education to patient/families and the healthcare team.
- Care Coordinators in high risk coordinate care for a group of patients with a specific diagnosis and/or complex discharge needs across the continuum. Provides assistance and support in collaboration with the healthcare team to ensure that patients are given all available resources to meet their healthcare goals and improve self-management of their health/disease process.
- Maintains confidentiality on relevant issues and information. Takes accountability for personal performance and goal achievement. Takes initiative to set high standards of honesty, integrity and performance for self and others.
- Collaborates effectively with team members, develops good relationships both inside and outside of the team. Constructively works through problems/issues without becoming defensive or antagonistic. Contributes ideas and supports decisions made by the team and the organization. Always treats others with dignity and respect.
- In accordance with all regulatory requirements, documents accurately, objectively and timely, the patient's plan of care and discharge disposition.
- Identifies patient safety and quality issues and reports to appropriate individuals. Uses high reliability principles to ensure patient safety and quality outcomes.
- Fulfills all compliance responsibilities related to position
- Performs other duties as assigned.
- 3+ years experience as a Registered Nurse
- 3+ years Healthcare Case Management experience (Nursing Home, Hospital, Home Care, etc.)
- Masters Degree in Social Work required
- CCM and/or ACMA certification or equivalent preferred
- Must have experience with an adult population of patients
- Excellent oral and written communication skills
- Basic computer skills
- Prioritize the daily workload and utilize tools dedicated to the position/function.
- Ability to deal with a high degree of public and patient contact and interaction, and make independent decisions, perform concurrent tasks, manage stressful situations and balance multiple priorities
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Job Type: Full-time
- Registered Nurse: 3 years (Required)
- Healthcare Case Management: 3 years (Required)
- Danbury, CT: Between 31 and 40 miles (Preferred)