The Care Coordinator RN has the responsibility to promote case management activities through
the health continuum, beginning in the acute setting. Case management begins with the
assessment of pre-morbid health status, current medical condition and post-acute needs. The Care Coordinator RN performs admission and concurrent continued stay reviews to ensure that services are being delivered at the most appropriate level of care to meet the client's needs and to secure reimbursement from payers.
Utilizing an interdisciplinary team approach, the Care Coordinator RN acts as a consultant and educator on matters referring to alternative levels of care, managed care issues, and community resources. In collaboration, to provide optimal patient care through, assessment, planning, implementation, and evaluation of neonatal, pediatric, adolescent, adult, and geriatric patients and families. This position also provides information such as certified LOS and reimbursement issues to physicians as needed to ensure the appropriate and timely disposition of the client to the next level of care. The Care Coordinator RN monitors and documents the progress of the plan, making revisions as needed, to assures a smooth transition to the next level of care at the time of discharge.
The Care Coordinator RN must respect beliefs and values while advocating for the client's right to self-determination and to make informed choices.
The Care Coordinator RN documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as re-admissions) and core measures. As indicated, delivers non-coverage letters as set forth by payer and/or regulatory compliance.
The Care Coordinator RN acquires and maintains knowledge and competencies related to the expectations of their position including an extensive knowledge of post-acute admission criteria (Rehab, LTAC and SNF etc.). Practice is aligned with the mission, vision and goals of the Integrated Health System. She/he participates in Quality Improvement initiatives.
This position does not provide patient care.