Care Coordinator (LCSW, LMSW or RN) FT Days

About the role

The care coordinator position encompasses the process of case management practice in partnership with the medical staff and members of the clinical team accountable for outcomes of selected patient populations. The care coordinator is accountable to the patient and the community and is responsible for facilitating the patient's safe, cost efficient, progression-of-care throughout the entire episode of acute care and assuring the patient's timely and seamless transition back to the community.

Responsibilities

• Facilitates triple aim initiatives by ensuring access to appropriate care.
  • Advocate for patients by assessing that patient healthcare needs are being addressed in the most appropriate level of care.
    • Understands and works in all hospital settings for patient coordination or care, such as the emergency department, ICU, Burn unit, Women & Infant, med/surg/telemetry, etc.
    • Screens patients to determine appropriate level of care coordination interventions based on risk factors related to barriers that impact progression of care, transition of care, and readmissions.
    • Affirmatively assesses patient situation by collecting information from patient and family, professional and non-professional caregivers, employers (as appropriate), and health records to identify individual needs to develop a comprehensive progression-of-care management plan and assessment that will address those needs.
    • Confirms admission diagnosis and identifies related quality metrics to promote medical compliance.
    • Promotes patient/family participation in all care and treatment decisions.
    • Educates members of the patient's healthcare team on the appropriate access to and use of various levels of care.
    • Recognizes and responds appropriately to risk factors.
  • Implements a wholistic and patient-driven approach to care management.
    • Assesses the effectiveness of services and their outcomes in concert with the interdisciplinary team, recommending appropriate plan modifications to ensure treatment objectives are met.
    • Promotes use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
    • Provides point-of-care coaching to medical documentation that accurately reflects intensity of services, quality and safety indicators, and patients' response to treatment.
    • Consults with medical advisors as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
    • Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, external case managers, and post-acute providers.
    • Facilitates and coordinates patient and family meetings to discuss goals of care, difficult treatment recommendations, new diagnosis, etc.
    • Facilitates complex psychosocial assessments and brief counseling on such topics as fetal demise, teen pregnancy, new cancer diagnosis, complex medical treatment needs, wound/burn care, trauma, guardianship, return to home barriers, goals of care, advanced directives, etc. as they impact patients' hospitalization.
  • Orchestrates the coordination of care throughout the patient continuum.
    • Serves as a primary liaison between and among physicians, patients, families, payers, external case managers, post-acute providers, and interdisciplinary clinical team.
    • Maintains appropriate documentation for each patient to include specific documentation of all planning, liaison, and coordination activities.
    • Collaborates with post-acute coordinators to monitor and facilitate the progress of completing discharge logistics.
    • Proactively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources.
    • Makes timely referrals to the Post-Acute Resource Center to expedite post-acute service arrangements.
    • Collaborates with nursing and members of the clinical team to provide patient/family education regarding discharge goals that require the team's expertise (medication administration, transferring to/from a car, oxygen use, etc.).
    • Researches discharge placement options, when home discharge is not possible, while continuing to focus on patient/family goals, interdisciplinary team recommendations, available payer benefits and private financial considerations which may impact placement.
    • Affirmatively assures discharge plan is addressed during daily rounds, keeping patient/family objectives in mind while modifying the plan as appropriate and posting on the patient's white board.
    • Updates all involved parties regarding progress, revisions and other information related to transition readiness.
    • Facilitates referrals to local, state, and federal resources and arranging patient/family counseling or support groups after discharge.
  • Steward of resource management.
    • Identifies, organizes, and secures the resources necessary to accomplish the goals set forth in the patient's treatment plan.
    • Facilitates the timely delivery of services to patients and families through effective management and utilization of available resources.
    • Interfaces with utilization reviewers to stay current on patient's eligibility for admission, continuing stay or readiness for discharge.
    • Perseveres in attempts to influence clinical and financial outcomes of care.
    • Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
    • Evaluates patient care outcomes to determine the effectiveness of the treatment plans for clinical and financial effectiveness.
    • Assertively manages resource utilization while appropriately navigating the patient's movement along the continuum of care.
    • Collaborates with attending and hospitalist physicians to influence appropriate utilization of resources and transitions from one level of care to another.
  • Coordinates a safe and timely transition of care for appropriate patients.
    • Advocates for the patient to expedite progression of care and ensure appropriate level of care.
    • Makes timely referrals to the Post-Acute Resource Center to expedite post-acute service arrangements.
    • Collaborates with nursing and members of the clinical team to provide patient/family education regarding discharge goals that require the team's expertise (medication administration, transferring to/from a car, oxygen use, etc.).
    • Researches discharge placement options, when home discharge is not possible, while continuing to focus on patient/family goals, interdisciplinary team recommendations, available payer benefits and private financial considerations which may impact placement.
    • Affirmatively assures discharge plan is addressed during daily rounds, keeping patient/family objectives in mind while modifying the plan as appropriate and posting on the patient's white board.
    • Updates all involved parties regarding progress, revisions and other information related to transition readiness.
    • Facilitates referrals to local, state, and federal resources and arranging patient/family counseling or support groups after discharge.
  • Provides supervision for nursing students, undergraduates, CSW/LMSW interns as appropriate.
    • Mentors undergraduate and/or nursing students.
    • Reviews documentation of CSW/LMSW interns.
    • Maintains supervision requirements for CSW/LMSWs in accordance with the Louisiana Social Work Practice Act and Louisiana Administrative Code, Title 46, Part XXC.

  Requirements

  Experience Required: None
  Preferred: Prior experience in a hospital or case management role

  Qualifications

  Education Required: Master's in Social Work (Current Louisiana RN licensure may be substituted)
  Certifications & Licensure Required: None
  Preferred: CSW, LMSW, or LCSW (For Social Workers only)

  Skills

  Ability to manage conflict, stress, and multiple competing work demands in an effective professional manner.
  Knowledge and ability to manage multiple patients of cultural diversity and low literacy issues in care provisions.
  Demonstrates knowledge of human behavior, socioeconomic factors in disease and illness, behavior patterns of the physically and mentally ill patient.
  Demonstrates outstanding communication skills and can establish constructive relationships with patients, families, and hospital associates.
  Demonstrates pro-active creativity in negotiating post-acute services with community providers and the finance department.
  Works well under pressure of time and shifting priorities.
  Demonstrates skill in written documentation and providing concise information to the medical team to facilitate care delivery.

  Special Skills or Knowledge

  Preferred: ACM or CCM certification

  HIPAA & SAFETY REQUIREMENTS

  • HIPAA - Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records without limitation both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, medical records related to quality data, patient financial information, patient billing 3rd party, patient related complaints, information related to patient location, religious beliefs and/or public health records.
  • Safety - Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wastes, sharps and linen, PPE, exposure control plans, hand washing, environment of care, patient identification, administers/collects medications/blood order, transports/monitors or observes patients with infusion pumps, and monitors clinical alarms.

  Performance Criteria & Standards

  • Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.
    • Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
    • Takes initiative in living our Everyday Excellence values and vital signs.
    • Takes initiative in identifying customer needs before the customer asks.
    • Participates in teamwork willingly and with enthusiasm.
    • Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
    • Keeps customers informed, answers customer questions and anticipates information needs of customers.
  • Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.
    • Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
    • Maintains accurate and reliable patient/organizational records.
    • Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.
  • Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.
    • Uses accepted procedures and practices to complete assignments.
    • Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
    • Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
    • Upholds the ethical standards of the organization.
  • Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job.
    • Participates in Performance Improvement activities.
    • Incorporates quality improvement standards in his/her job.