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The Care Transitions Coordinator is responsible for coordinating and facilitating patient discharge planning during hospitalization, ED visits and transitions to and from skilled nursing facilities, long term acute care, and rehab facilities. The Coordinator works alongside physicians, nurses and social workers and other disciplines within the care team, including outside agencies, to expedite the appropriateness, effectiveness and timeliness of care. Candidate applies clinical expertise and medical appropriateness criteria to resource utilization and discharge planning, and manages the resources necessary for cost effective, quality patient care. This position includes meeting the needs and providing services to all age groups-infancy through geriatrics.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate’s Degree in Nursing AND Five years clinical experience in a healthcare setting OR Bachelor’s Degree in Nursing AND Three years clinical experience in a healthcare setting.

2. West Virginia licensure as a Registered Professional Nurse or licensure as Registered Professional Nurse in another state with a temporary West Virginia practice permit.

PREFERRED QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Nursing

EXPERIENCE:

1. Medical Management for Medicare and/or Medicaid populations preferred

2. Prior care coordination experience

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Ability to interact with clinical departments as necessary to clarify components of the treatment or discharge plan.

2. Assesses, facilitates, and monitors the plan of care in conjunction with the patient and/or family/significant other.

3. Conducts concurrent chart review of selected patient populations, assesses the appropriateness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues, and completeness of medical record documentation.

4. Identifies and follows currently admitted and discharged patients in the Hospital, SNF, LTACH, or Rehab setting through a 14 day discharge period to facilitate a smooth and safe transition for the patient.

5. Evaluates patient needs/requests during needed transitions of care

6. Identifies issues/problems and makes appropriate recommendations. Communicates with patients, families/ significant others, medical staff, caregivers

7. Serves as a facilitator/advocate for patients and families in the resolution of problems related to the established plan of care and procurement of services.

8. Participates in Peak Health UM meetings, when applicable, to identify patient discharge needs prior to discharge to create a smooth transition for the patient.

9. Works with the Peak Health case management team, when applicable, to identify barriers and help facilitate any discharge referrals as needed including, but not limited to: Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.

10. Utilizes care planning screens, when available, in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions

11. Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to departmental policy

12. Refer patients, as needed, for continued case management into population health programs or other community resources as needed.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning

3. Excellent written and oral communication

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction

5. Attention to detail

6. Proficiency with Microsoft Office

Additional Job Description:

fully remote position

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

415 SYSTEM Population Health Management