Lawrence General Hospital Clinical Care Coordinator in Lawrence, Massachusetts
The Clinical Care Coordinator is responsible for managing patient flow and progression activities within their assigned unit(s). The CCC will serve as the lead of a multidisciplinary team to include clinicians, clinical leadership, nurses, pharmacists, physical therapists, physicians, residents/interns and social workers to manage optimal patient outcomes and length of stay efficiency. This position will be charged with directing team members, and patient care progression, throughout the care continuum while being accountable for removing any barriers hindering the patient discharge process. The CCC will serve as a clinical resource and role model for staff. The CCC will demonstrate a high level of independent decision making and will be accountable for driving outcomes around a patient’s length of stay.
Initiates and assures appropriate sequencing of care / interventions for optimal results through the care continuum with consideration for financial risk populations (i.e. Bundles, Medicare Shared Savings Plan (MSSP), Medicaid ACO, Service Line Programs (Spine/Ortho)).
Uses independent judgment to direct team members around patient care progression. Identifies barriers to safe discharge, assigning clear accountability for each follow-up and barrier and recording the assignment to keep everything organized. Presents outcomes at huddle.
Challenges decisions or barriers that will result in a patient not meeting their LOS Target, seeking alternatives to keep the patient on track. Escalates any potential outliers identified at 48 and 24 hours prior to target discharge date.
Holds team members accountable to the patient care progression process.
Coordinates simple discharge planning, i.e. DME, VNA, transportation. Coordinates discharge plan related to patient needs and payer requests.
Current Massachusetts registered nursing license or Massachusetts licensed independent clinical social worker (LICSW).
Baccalaureate degree in nursing, business and other care related field or master’s degree in social work (MSW).
Minimum of 3-5 years of direct acute clinical experience.
Knowledge of discharge planning, risks contracts, value based care, and total medical experience.
Ability to analyze clinical, financial and social solutions, identifying problems and alternative courses of action.
Flexible, resourceful and creative in problem solving.
Proven prioritization skills.
Ability to act independently and present information clearly and concisely.
Excellent interpersonal skills with all internal and external stakeholders.
Previous supervisory experience.
Clinical expertise in specialty area.
Master’s degree in nursing, social work, business or other care related field.