4square Medical Staffing
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CARE COORDINATOR

 

Specific functions within this role include:• Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education• Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs• Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers• Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge.• May have other duties assigned

 

Assessment- Based on preliminary screening of patients, initiates assessment of patient’s chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.- Partners with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.- Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patient’s care progression and discharge plans..- Meets with physicians and care team routinely to collaborate on timely and efficient patient management. Care Progression- Collaborates with physicians and care team to facilitate communication regarding patient’s care progression to ensure timely and efficient delivery of care.- Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.- Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.- Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution
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