Maximize the components of care coordination to improve patients’ healthcare experience and outcomes, by utilizing care coordination tools, criteria and protocols to:
provide patients with chronic and acute conditions the support, education and assistance in the prevention and/or maintenance of their disease and/or health and wellness state;
increase patients compliance with treatment plans;
engage community resources to support the patient’s optimal functioning; and improve collaborative coordination of care to affect waste and inefficiency.
Review activities that take place during a patient’s hospital stay and/ or in a home or community setting to include review of evidence that care is being delivered at the appropriate level.
Review evidence that discharge planning began at admission or start of services.
Coordinate discharge planning needs with facility, health services providers and patients.
Facilitate provider contact as needed to coordinate patient’s care needs.
Identify high risk patients for disease management and care coordination and work with patient, physician and other health care providers to establish a plan of care to meet the patient’s individual needs.
Provide telephonic and/or face to face follow up with patients for care coordination services.
Conduct or oversee “Welcome Home” calls to patients post discharge from inpatient or other levels of care and ensure documentation is kept current in the care coordination documentation system.
Telephonic contact and/or face to face with identified patients to explain the care coordination program, assess needs, educate patient regarding the disease as appropriate.
Telephonic contact and/or face to face to instruct the patient on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, and physician follow up visits; document the contact into the care coordination documentation system.
Perform home visits, with verbal permission from patient and/or caregiver, for patient support, when appropriate.
Phone and/or face to face support on setting up and using care coordination tools or equipment placed in the patient’s home.
Consult and work closely with the Medical Director regarding care that doesn’t appear to meet evidence based medicine and medical necessity.
Conduct daily tracking of caseload as assigned.
Prepare for and attend ACO committee meetings as assigned.
Comply with all departmental policies and procedures.
Participate in departmental and company in-services as appropriate.
Take calls from patients and providers and give them appropriate information to help coordinate services.
Document all contacts in the care coordination documentation system.
Manage patients in current disease management programs, completing and revising as necessary, the information in care coordination documentation system.
And all other duties assigned by manager or supervisor.
Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas
Organizational skills with the ability to handle multiple tasks and/or projects at one time
Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company
Analytical and interpretation skills including departmental, utilization, financial and operations data
Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time
Problem solving skills with the ability to look for root causes and implementable, workable solutions
Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
RN with current state licensure
Maintain a valid driver’s license for any required facility on-site and home visits
CCM and/or related certification or eligible to take exam within two years of employment is preferred
Experience working with CMS
Bilingual is a plus
Computer experience should include working with Microsoft Word, Excel and Outlook at the intermediate level at a minimum
Universal American Corp. is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.