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Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
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Ensures that an admission review has been completed within one working day after admission.
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Transitions with the ED Care Coordinator and Transfer Coordinator for patients admitted to inpatient/observation level of care.
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Performs a comprehensive assessment of patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues.
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Establishes rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information.
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In conjunction with the physician, the patient and interdisciplinary team, establishes a comprehensive plan of care to appropriately address clinical milestones.
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Communicates plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Facilitates communication between the physician, interdisciplinary team, patient and family.
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Gathers sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost effective manner.
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Is a resource to staff and physicians regarding appropriateness of admission and continued stay, levels of care (including related documentation requirements), quality of care concerns and criteria/guidelines/protocols utilized in care planning and resource utilization.
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Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes. Modifies plan of care as patient/family needs change to accomplish goals established in the plan of care.
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Coordinates patient transfer to the appropriate level of care. Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed. Communicates resulting decisions to patient/family, physicians and members of healthcare team, according to regulatory guidelines and hospital policies.
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Identifies opportunities to improve care/service. Assists in development and implementation of care performance improvement plans based upon analysis of patterns and trends identified from data collection and observations.
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Demonstrates understanding of payer prior approval requirements and the various health care delivery systems and payer plan contracts. Ensures timely communication with third party payers and/or review organization as necessary and provides information to federal, state, and privates payers and/or review organizations so that determinations regarding benefits and coverage may be made. Provides clinical information requested by providers as part of the concurrent appeal process.
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Documents all care management assessments and interventions. Inserts most current discharge planning documentation into medical record.
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Assigns process, social and physician related avoidable days according to established policy and procedure.
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Ensures that the appropriate level of care is maintained through ongoing continued stay reviews using UR Committee approved criteria. Makes recommendations when alternate levels of care are indicated.
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Escalates to the UM Committee through the physician advisor or EHR when unable to resolve issues with the attending physician, and as required by federal and regulatory requirements.
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Educates physicians and staff to understand admission status, appropriate patient placement and other regulatory requirements.
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Works with ED and Transfer Coordinator to ensure evidence based order sets are initiated upon admission, when available. Follows up to ensure that order sets and clinical pathways are being implemented as available. Monitors and intervenes for variances.
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Proactively discusses discharge planning needs with the physician and interdisciplinary team. Establishes an initial discharge plan in conjunction with patient and families within 24 hours or as soon thereafter of an assessed need or referral is sent.
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Rounds regularly with physicians to establish plan of care, and to ensure that care is proceeding in an efficient and effective manner. Follow up to ensure that tests and treatments are proceeding efficiently, and that results are available to physicians on a timely basis.
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Ensures that the care plan is updated as appropriate, through clinical progression of the patient toward clinical milestones updating the team and patient and family accordingly.
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Closely monitors the progression of care for the observation patient, and ensure appropriate utilization of resources and efficient throughput for this patient population.
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Facilitates the initiation of diagnostic services, treatment planning, and therapeutic treatments. Assesses and intervenes to ensure that the patient’s treatment plan is current, appropriate and efficient.
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Identifies and ensures a safe discharge plan and that it is completed at least 24 hours prior to discharge whenever possible.
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Refers to Social Worker or Discharge Planner for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (physical therapy, pharmacy, etc.) to provide safe discharge as appropriate.
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Ensures that any information appropriate to facilitate continuity of care post discharge is communicated to post acute provider via discharge paperwork or via phone per departmental documentation guidelines.
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Develop strong relationships with community health resources to ensure appropriate patient access after discharge. Completes timely referrals to post discharge providers, ensuring efficient patient flow and adherence to federal and regulatory requirements.
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Develops, maintains and provides community resource information to patients.
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Helps patients obtain a PCP (Primary Care Physician) and affordable discharge medications and resources as necessary.
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Ensure appropriate follow-up appointments are made and patient is knowledgeable about post discharge activities.
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Issues notices of non-coverage/denial letters to patients based on results of physician reviews and in compliance with Medicare/HSAG, federal and state and department guidelines.
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Ensures that the Medicare Important Message has been delivered according to hospital policy.
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Monitors and manages clinical outcomes and intervenes on issues that have the potential to impact quality.
- Performs other duties as required.
