The RSO care coordinator for Medicare Preferred patients is responsible for care management of patients through the continuum of care. Care coordinator staffing is based on membership which will determine the specific role of each care coordinator. Utilizing a patient centered approach, the care coordinator will care manage a panel of frail elderly patients who have been identified as the most complex with the highest risk of readmission as well as the patients identified in the next tier who require chronic care management. The care coordinator directly interfaces with physicians, health care teams, patients and their unpaid care givers in managing the patient’s care. The care coordinator utilizes sound clinical judgment and critical thinking skills to coordinate and authorize services based on entitled benefits and defined criteria. Performs in accordance with the facility’s policies and procedures. Follows the facility’s standards for ethical business conduct. Conducts self as a positive role model and team member. Participates in facility committees, meetings, in-services, and activities.
Principle Duties and Responsibilities:
1. Comprehensive care management and care coordination for a panel of geriatric patients.
- Geriatric assessment based on complexity of patient (Complex or Chronic Management)
- Development and communication (with patient, caregiver and primary care physician/health care team) of a comprehensive care plan based on evidence-based best practice for chronic illness
- Pro-active management and follow-up (telephone, PCP office and in some circumstances it may be beneficial to the patient if the care coordinator is able to assess the patient during a home visit) according to care plan
- Management and coordination of all transitions in care:
- Communicate care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialist)
- Ensure that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialty care)
- Direct caregiver support, including ad hoc telephone advice
- Facilitation of patient and caregiver access to community resources relevant to patient’s needs, including referrals to transportation programs, Meals on Wheels, senior centers, chore services, et cetera.
- Incorporation of self-care and shared decision making in all aspects of patient care.
2. Utilization Management
a. Appropriate leveling of patients in all settings based on approved
criteria/Medicare guidelines - hospital, acute rehab, skilled nursing facility and
homecare
- Management of the patient’s health benefits
- Authorizations for all approved services following health plan standards and complying with state, federal and other applicable standards
- Compliance with documentation standards
- Denials follow all health plan guidelines
- Referral to community services as appropriate
3. Maintain strict patient confidentiality.
4. Other duties as assigned.
Qualifications:
Current Massachusetts licensure as a Registered Nurse, BSN or equivalent combination of education and experience required. A minimum five years of nursing experience with geriatric patients is preferred. Valid drivers license and reliable means of transportation.
Skills and Abilities Required:
Ability to travel frequently to hospitals, skilled nursing facilities and other sties where patients receive care (as indicated by patients’ needs).
Posses excellent interpersonal skills, with a flexible and creative approach to problem solving. Excellent communication skills both written and verbal, and an ability to listen and be assertive, as required.
Ability to work independently and to work effectively as a member of an interdisciplinary team, displaying good clinical judgment and decision-making skills.
Proficient in computer use and the Internet.
Have a commitment to “coaching” (rather than “teaching”) patients to improve their health behavior to attain their health-related goals.
Working Conditions:
The work environment is one of a typical office work environment. Extensive computer work, such as data entry, verifying system data, correcting and updating information is necessary for maintaining databases, and preparing statistical reports. While performing the duties of this job the employee is frequently required to sit, walk; stand; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.
Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.
For more information, visit steward.org
