Care Coordinator - Onsite - Round Rock,TX - Hybrid--RN, PT, OT, SP

Overview

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The Care Coordinator
- Onsite plays an integral role in optimizing patients' recovery journeys. The Care Coordinator
- Onsite completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the member's PAC journey. By serving as the link between patients and the appropriate health care personnel, the Clinical Review Coordinator
- Onsite is responsible for ensuring efficient, smooth, and prompt transitions of care.

• Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays
• Review target outcomes, and discharge plans with providers and families
• Complete all SNF concurrent reviews, updating authorizations on a timely basis
• Collaborate effectively with the patients' health care teams to establish an optimal discharge. The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.
• Assure patients' progress toward discharge goals and assist in resolving barriers
• Participate weekly in SNF Rounds providing accurate and up to date information to the Home & Community Care Delivery Sr. Manager or Medical Director
• Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed
• Attend patient/family care conferences
• Assess and monitor patients' continued appropriateness for SNF setting (as indicated) according to CMS criteria
• When Home & Community Care Delivery is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the NOMNC when appropriate
• Coordinate peer to peer reviews with Home & Community Care Delivery Medical Directors
• Support new delegated contract start-up to ensure experienced staff work with new contracts
• Manage assigned caseload in an efficiently and effectively utilizing time management skills
• Enter timely and accurate documentation into coordinate
• Daily review of census and identification of barriers to managing independent workload and ability to assist others
• Review monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager, as needed, to assist with the identification of opportunities for improvement
• Adhere to organizational and departmental policies and procedures
• Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws
• Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business
• Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
• Adhere to all local, state, and federal regulatory policies and procedures
• Promote a positive attitude and work environment
• Attend Home & Community Care Delivery meetings as requested
• Hold patients' protected health information confidential as required by applicable laws, regulations, or agency/institution procedures
• Perform other duties and responsibilities as required, assigned, or requested

• Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist
• 5+ years of clinical experience
• Candidate hired will support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion
• Reside within or near the country listed on the job description
• Driver's License and access to a reliable transportation

• Experience working…