Skilled Inpatient and Transitional Care Coordinator

naviHealth - Kent, WA3.3

Full-timeEstimated: $61,000 - $78,000 a year
Overview of Position/Basic Job Description

The naviHealth BPCI Dual Role Care Coordinator acts as a Transitional Care Coordinator (TCC) and SNF In-patient Care Coordinator (SICC) when market volume or geographic determine this is the best approach. The Dual Role Care Coordinator plays an integral role in the patient’s journey towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team in both the Acute Care setting and Post-Acute Care (PAC) settings. The Care Coordinator is responsible for identifying the appropriate first (PAC) setting in Acute and utilizes nH Predict to align expectations and discharge planning efforts in PAC. In both settings the Care Coordinator evaluates a defined population for transitional needs post-discharge to improve outcomes. The Care Coordinator engages the hospital care team, the physicians, post-acute care providers, the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transition of care and improving the patient journey.

Primary Responsibilities

This role is performed onsite at facilities or telephonically as directed by the manager.
Services are provided in a collaborative process that assess, plans, implements, coordinates, monitors and evaluates options and services required to meet the patient’s post-acute health needs, using communication and available resources to promote quality, cost-effective outcomes.
Maintains nH Coordinate case documentation per established standards
Provides telephonic post-discharge support to assist a defined population of patients in meeting short needs to prevent readmissions. This may include collaboration with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care.
The Care Coordinator partners with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers and to connect the patient to community resources and additional services.
Addresses end of life issues including hospice and palliative care options.
Practices cultural competency with awareness and respect for diversity.
Facilitates the development of a culturally sensitive individualized transitional care plan for services that including clinical, psycho-social, and environmental needs. Monitors and evaluates the effectiveness of the plan. Makes recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated.
Provides individualized evidence-based condition specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.
Adheres to organizational and departmental policies and procedures.
Maintains confidentiality of all PHI information in compliance with HIPPA, federal and state regulations and laws.

Transitional Care Coordinator Specific Functions

Assists in identifying patients who qualify for the BPCI-A program
May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally-based assessment technology tools. Provides outcome targets to appropriate audience.
Utilizes naviHealth proprietary technology and industry standard evidence-based tools for consideration of appropriate level of care, readmission risk and needed interventions.
Collaborates effectively with the patient’s interdisciplinary health care team to coordinate an optimal transition plan to the most appropriate PAC setting. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc. The patient and caregiver are involved in the decision making process to minimize service fragmentation during care transition.

Assess and monitors patient’s appropriateness for care setting (as indicated) according to nH Predict™, InterQual criteria and/or industry standard evidence-based criteria. Communicates with Hospital Case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed.

Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for process improvement.
Participates in weekly readmission and other type rounds as needed based upon opportunities.

SNF In-Patient Care Coordinator (SICC) Specific Functions

Collaborate effectively with the patient’s interdisciplinary health care team to coordinate target length of stay and an optimal transition plan to the most appropriate setting. The health care team includes physicians, PAC discharge planners, referral coordinators, physical therapist, etc. The patient and caregiver are involved in the decision making process to identify personal care/health goals and to minimize service fragmentation during care transition.
Attends weekly SNF Rounds and other meetings
Performs functional assessments of patients using clinical skills and proprietary decision-support tools upon admission to PAC and at weekly intervals and upon discharge.
Participates in SNF IDT (Interdisciplinary Teams Rounds) weekly providing accurate and up to date information to the naviHealth Management team.
Engages with patient, family or caregiver either telephonically or on-site weekly and as needed including attending patient/family care conferences.
Manages assigned caseload in an efficient and effective manner utilizing good time management skills.


Keeps current on federal and state regulatory policies related to utilization management and care coordination ( CMS guidelines, Health Plan policies and benefits)
Pursue multi-state licensure to meet business needs
Adheres to organizational departmental policies and procedures
Adheres to all local, state and federal regulatory policies and procedures
Must promote a positive attitude and work environment
Attends naviHealth meetings as requested
Performs all other duties as assigned
Holds as confidential the patient’s protected health information as required by applicable laws, regulations, or agency/institution procedures.


Registered Nurse or Therapist (PT, OT) with current, active unrestricted licensure required; RN preferred
5 years of clinical experience.
Case Management experience with CCM preferred.
Patient education background, rehabilitation, SNF and/or home
health nursing experience a plus.

Experience working with geriatric population preferred.
Excellent documentation and technology skills required
Self-starter with the ability to prioritize daily work load.
Strong interpersonal and communication skills (both verbal and written).
CMS and managed care knowledge preferred.

About naviHealth

NaviHealth partners with health plans, health systems and post-acute providers

to manage the entire continuum of post-acute care. We utilize evidence-based protocols to optimize care and bundled payment methodologies to align all stakeholders. The result: optimized care and outcomes, reduced inpatient days, reduced hospital readmissions, and increased patient satisfaction.

NaviHealth ™ is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.