Mercy Medical Center Clinton Clinical Care Coord-Unit in Holyoke, Massachusetts
3030_4230 Utilization Review-4230
Expected Weekly Hours:
The Clinical Care Coordinator (C3) - Unit is responsible for providing direction and leadership to staff. Participates as a member of the multidisciplinary treatment team and acts as liaison between external entities, emergency services, nursing, finance, physicians, and medical records to ensure appropriate bed is assigned, patient care needs are met and treatment plans are executed in the appropriate level of the continuum. Provides clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures. Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement and quality initiatives.
Job Description Details:
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
Assumes ten (10) hour responsibility and accountability. Coordinates and directs level of care appropriateness with admission status determination. Uses discretion and independent judgment in applying initial screening criteria standards as well as Medicare regulations and evidence of coverage.
Collaborates in developing goals, evaluating staff and maintaining regulatory compliance. Serves as a role model as well as a resource to staff, patients and families, and the interdisciplinary team. Coordinates unit specific quality / process improvement initiatives.
Demonstrates leadership abilities and assumes a supervisory role.
Collaborates with the Director / Nurse Manager on the hiring, corrective action and evaluation processes for staff as well as labor relations issues / concerns. Assesses and/or completes staff performance appraisals.
Assesses the learning needs of staff and assumes responsibility for ensuring continued professional growth and development by promoting an environment conducive to learning. Provides educational opportunities for hospital clinical staff via in-service programs regarding level of care criteria and managed care principles.
Ensures the delivery of quality patient care within nursing unit(s). Conducts administrative and clinical support functions in a manner that facilitates effective measures of operation of the hospital during assigned hours. Directs the nurses and unit staff in coordination of care.
Completes planning using high risk admission and discharge criteria set. Anticipates needs of medical / psychosocial in high risk patients, e.g. chronic diagnoses, top ten DRGs, patients frequently accessing care, etc. Initiates and follows appropriate clinical pathways and plans of care. Assigns all patient beds and staff assignments for all admissions based on patient acuity, productivity and skill level.
Performs daily rounding with physician and care team to proactively progress the patient’s plan of care and discharge. Queries the physician, residents / interns, mid-level clinicians and other clinicians for clarification and to obtain accurate and complete documentation as needed, based on current clinical findings, prescribed treatment, medical interventions and / or procedures.
Reviews urgent cases authorized for one (1) day, within 24 hours of admission. Reviews concurrent cases and discharge plans in timeframes determined in the review process with external entities.
Completes a discharge needs assessment on all admissions. Coordinates simple discharge planning, i.e., DME, transportation. Coordinates discharge plan related to patient needs and payer requests. Assures patient education is complete and documented. Acts as a clinical role model to the nursing staff.
Ensures appropriate clinical documentation to support level of care. Analyzes the patient’s current clinical status, treatment plan and past medical history to identify potential gaps on physician documentation. Identifies the principal diagnosis and all secondary conditions, co-morbidities, complications and procedures that have been documented in the medical record.
Monitors quality and appropriateness of treatment and discharge planning, ensuring that goals are obtainable and measurable. Provides information regarding options for discharge planning as outlined by payer benefits.
As required, provides clinical data as part of the telephonic or electronic review process to external parties to ensure continued stay authorizations.
Coordinates appeals with MD’s, APRN’s and external entities. Responsible for generating appeal requests post discharge. Conducts clinical reviews with third party payers. Initiates and monitors clinical and administrative appeals in order to maximize reimbursement for provision of service. Conducts intermittent chart reviews for all patients admitted to inpatient programs to ensure that patients meet level of care for admission and continuing care. Utilizes Interqual to document level of care appropriateness.
Reports any uncovered or at risk days to Director Care Coordination and the treatment team. Appropriately interfaces and attends “denials” meetings with patient accounts regarding uncovered days and status of appeals.
Acts as liaison between patient, physician, family and health care team regarding plan of care and progress towards goals.
Proactively identifies and removes barriers that impede the progress of care. Assures appropriate sequencing of care / interventions for optimal results and smooth transition along hospital care and continuum.
Performs standard of care / core measure audits and accreditation / compliance activities.
Adheres to all standards and policies regarding safety / patient safety initiatives.
KNOWLEDGE, SKILLS AND ABILITIES:
Work requires current license as a Registered Nurse in the State of Massachusetts. A Bachelor’s degree in Nursing, business or other health care related field is preferred with a minimum of three (3) years clinical experience. Clinical expertise in specialty area. Previous supervisory experience strongly preferred.
BLS certification required. ACLS and other certifications per unit requirements.
Ability to analyze clinical, financial and social situations, identifying problems and alternative courses of action. Willingness to be flexible, resourceful and creative in problem solving. Work is not standardized and requires a high degree of prioritization skills.
Ability to act independently and offer suggestions and new ideas for improving performance and operations. Ability to guide and direct the health care team to assure optimal outcomes.
Ability to organize and present information clearly and concisely. Keeps supervisor, peers, physicians, interdisciplinary team members, patients and families informed about progress, problems and developments.
Work requires the ability to proofread and check documents for errors as well as the ability to use a keyboard to enter, retrieve, and transform data.
Demonstrated interpersonal skills in order to effectively communicate with physicians, patients, families and other members of the interdisciplinary team.
Constant work demands and irregularity of hours create considerable inconvenience for home and social life planning, such as frequent availability, or, constant shift rotation, or location imposes frequent interruptions, and distractions that are both bothersome and not inherent in the work. The work requires frequent substantive involvement in stressful situations causing considerable strain routinely.
May require considerable physical effort on an as needed basis, as in lifting, pulling, or pushing unyielding loads (heavy, bulky, awkward, more than 40 pounds).
Reports to the Director of Care Coordination.
Responsible for supervising the work of any assigned staff in unit.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
Trinity Health offers rewarding careers in a community environment with all the advantages of working at one of the nation's largest health systems. We provide high-quality, people-centered care in 22 states through our network of hospitals, facilities, community-based services, and continuing care locations - including home care, hospice, Program of All Inclusive Care for the Elderly (PACE), and senior living facilities. If you are looking for a rewarding clinical or administrative position, you'll find exceptional career possibilities, opportunities for advancement and a job with meaning at Trinity Health.
Trinity Health employs more than 131,000 colleagues across 22 states. We honor and embrace a diverse representation of people, ideas and backgrounds. Our dedication to diversity is evident in our commitment to training, education, recruitment, retention and development, as well as community partnerships and supplier diversity.
Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences and health practices of the communities we serve and to apply that knowledge to produce positive outcomes. We recognize that each of us has a different way of thinking and perceiving our world, and that our differences not only serve to unite us, but also lead to innovative solutions.