Care Coordinator_Hometown Health

Under the supervision of the department leadership this position uses a collaborative nursing process that assesses, plans, implements, coordinates, monitors, and evaluates options and services based on available community resources and health insurance benefits. Medical necessity evaluations are made based on nationally recognized criteria for all prior authorizations, admissions and concurrent reviews and in coordination with the health plan Medical Director or Chief Medical Officer. Discharge planning assistance collaborative with hospital staff in order to channel members to contracted providers and maintain services with current providers when needed to prevent member disruption. Care Coordinator RNs coordinate with other team members to ensure the members experience exceeds expectations.

The Care Coordinator has the responsibility to promote care coordination activities to provide for individual member’s health care needs through the continuum of care. This includes: management in the setting of acute care (hospital), recovery care (Rehab/SNF), Case Management and the pre-certification process for all lines of products.

The Care Coordinator collaborates with all medical team members throughout the continuum and educates the member/ family on managed care issues, community resources and plan benefits. This collaboration promotes positive outcomes (quality) and the utilization of patient/member care resources in an efficient and cost-effective manner within the benefit structure.

The scope includes potential for cross training within the continuum of all care coordination roles to cover for departmental vacations, illness and vacancies.

Knowledge, Skills & Abilities

• Strong interpersonal communication skills both written and verbal,

• Collaborate with member, family, providers and team members to develop a culturally sensitive plan of care utilizing available finite resources,

• Coordinates alternative community resources to include home health care, durable medical equipment, meals on wheels, hospice, etc. to keep the member safe in the environment of their choice and in alignment with the member wishes,

• Manages inpatient admissions in a standard manner applying guidelines to ensure member continues to move along the continuum of care,

• Applies medical necessity guidelines to complete utilization review procedures to ensure the member is receiving quality cost effective care in the appropriate setting,

• Transitions member to other team members as needed depending on environment and need,

• Knowledge of continuous quality improvement process,

• Knowledge of applicable regulatory requirements and community resources,

• Respects the beliefs and values of Hometown Health members while advocating for the client’s right to self-determination and make informed choices,

• Documents all medical necessity determinations, member contacts, and discharge plans in utilization review system and appropriate notes in the case management module

• Knowledge of group and individual health insurance plans, Medicare Advantage Plans, Centers for Medicare and Medicaid Services (CMS) and Division of Insurance regulations and URAC accreditation requirements.

This position does not provide patient care. This position makes no clinical adverse determinations.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Appropriate education to obtain and maintain Registered Nursing licensure in the State of Nevada.

Experience:

Minimum two years of clinical experience working in an in-patient or outpatient setting required. Two to three years of previous managed care utilization review management or case management, experience recommended.

License(s):

Current and unrestricted State of Nevada Registered Nurse license or licensure from State in which they have residency required

Certification(s):

Case Management; Professional Utilization Reviewer or Managed Care Certification recommended.

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.