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Title Clinical Care Coordinator ^60168
Req Number 13-00138
Open Date 1/16/2013
Clinical Care Coordinator Summary: The Clinical Care Coordinator comprehensively plans for Care Management of targeted patient populations. Performs resource management, including denial management, utilization management, access to the appropriate level of care, discharge planning, care facilitation, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes
Essential Duties and Responsibilities:
Utilization Management, Financial Management and Quality Screening for assigned patients:
• Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards, policy and procedure.
• Responsible for completion of all clinical reviews for patients admitted and discharged over the weekend and for discharged patients in which payors required additional information.
• Utilizes InterQual criteria to ensure appropriate level of care for inpatient status as well as screening for access via emergency room, UHA Clinics and MD offices.
• Screening for appropriateness for admission to WVUH Skilled Nursing Unit.
• Screening for appropriate authorization and level of care for admission to WVUH Ruby Same Day Surgery and IP Surgery suite.
• Communicates with Resource Center and /or third party payors to facilitate covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (ie. Peer to Peer) and follows up to resolve problems with payors as needed.
• Collaborate for appropriate resource and financial management which may include, but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, patient benefit coordination, assessment of working DRG and/or collaboration with Clinical Documentation Management Program, assessment for appropriate usage of Health Care Resources/clinical cost efficiency.
• Educates hospital staff and physicians to the payor regulations to prevent denials.
Appeals/Denial Management and Audits
• Assists in responding to concurrent reviews and providing information as necessary to avoid denials for patient admission.
• Negotiates concurrent denials and communicates findings to Finance and Outcome Managers.
• Applies appropriate utilization criteria to assist with providing information to ensure medical necessity of patient admissions.
• Responsible for appealing all concurrent and retrospective medical necessity and preauthorization denials issued by federal and commercial payors. Reviews billing edits related to medical necessity prior to write-off.
• Plans appeal strategy and submits written appeal within the payors required
• Appeal timeframe with assistance from Care Management Medical Director.
• Ensures denial and appeals are tracked and trended and reports to Director Care Management.
• Assist with billing audits from third party payors or required by regulations (i.e. RAC, MAC, Probes…)
Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education:
• Collaborates with all members of the Multidisciplinary Team to facilitate the Clinical Care Coordinator process for designated caseload. Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
• Addresses/resolves system problems impeding diagnostic or treatment progress with the observation population proactively identifies and resolves delays and obstacles to discharge
• Manages all aspects of discharge planning for assigned patients
• Meets directly with patient/family to assess needs and develop an individualized discharge plan in collaboration with physician
• Coordinate with healthcare team to determine if patient education is completed before discharge.
• Provide education as needed to staff, physicians, and patients for transitional planning needs
• Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and transitional/discharge plan changes.
• Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation
• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
• Refers cases and issues to appropriate personnel, ie. Medical Director, Outcome Manager RN Manager or Director, in compliance with department procedures and follows up as indicated
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues, involving RN Manager as necessary.
• Refers appropriate cases for social work intervention based on dependent criteria
• Initiates and facilities referrals transitional services which may include but are not limited to home health care, hospice, medical equipment and supplies
• Documents relevant discharge planning information in the medical record according to Department standards
• Facilitates transfer to other facilities for targeted patient population
Clinical performance improvement, outcome management and quality activities:
• Uses data to drive decisions and plan/implement performance improvement strategies related to Clinical Care Coordinator for assigned patients, including fiscal, clinical and patient satisfaction data
• Uses quality screens in Allscripts to identify potential issues, ie. Avoidable days and readmissions
• Collects delay for services and other data for specific performance and/or outcome indicators as determined by department
• Participates in development, implementation, evaluation and revision of clinical pathways and other Clinical Care Coordinator tools and serves as a member of the clinical resource/team, including participation of staff interviews/screening for hire.
• Educate the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles
• Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiatives
• Identifies at-risk populations using approved screening tool and follows established reporting procedures
• Monitors clinical and financial indicators (i.e. length of stay (LOS)) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas as viewed on Care Management’s Dashboard
Performance Standard: Adheres to the established Performance Expectations for WVUH Employees in the areas of People, Service, Performance Improvement, and Shared Values & Culture. Adheres to the Care Management Department Scope of Service policy and Standards of Practice policy.
• Bachelor’s Degree in Nursing preferred
• Current West Virginia licensure as a Registered Professional Nurse or licensure as Registered Professional Nurse in another state with a temporary West Virginia practice permit.
• Prior case management experience preferred
• 3 years clinical experience in a hospital setting required
Department CARE MANAGEMENT ^403
WVUH Shift Afternoon
WVUH Full-time/Part-time Full-time (40 hours)
Internal Transfer Only None Specified
About the Organization Looking for a challenge? If you are motivated, talented, and eager, there's a future for you at WVU Hospitals. We are looking for people with the desire to make a difference in healthcare.
WVU Hospitals, a 531-bed tertiary care center, teaching institution, that includes:
Ruby Memorial Hospital
WVU Children's Hospital
Chestnut Ridge Center (behavioral medicine)
Jon Michael Moore Trauma Center
Physician Office Center
Mary Babb Randolph Cancer Center
Betty Puskar Breast Care Center
WVU Heart Institute
Clark K. Sleeth Family Medicine Center
Rosenbaum Family House
Cheat Lake Physicians
Center for Reproductive Medicine
Pain Management Center
Wound Management Center
Sports Medicine Center
Sleep Evaluation Center
WVUH-Eastern Division (in the eastern part of the state)
Our employees are our most valuable asset. We offer competitive pay and benefits because we want to attract and retain employees who will support our mission of high quality patient care.
WVUH Hours per Week 40
Notes to Applicant This position is for Utilization review
WVUH Start/End Time 3p-11p