Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:
The Patient Care Coordinator facilitates and coordinates care for all assigned patients to progress the patient and achieve positive clinical outcomes and financial impact. The PCC collaborates with the provider, nursing and other health care team members on interventions to promote positive clinical outcomes for the patient. The PCC develops and implements a discharge plan for each patient as required, and collaborates with social workers and discharge planners regarding implementation of plan of care, as well as placements, legal issues, psychological needs impacting patient treatment. The PCC ensures that the discharge plan is ready when the patient is medically ready to transition to the next level of care. The PCC validates the status of patients to ensure compliance with the Wayne UNC Health Care Utilization Management Plan.

Responsibilities:
1.Patient Care Coordination Daily Management - Facilitates and coordinates care for assigned populations to include daily follow-up to ensure:
a.Patients have been prioritized and new admissions have been identified and assessed.
b.Physician orders have been implemented.
c.Interventions by nursing and ancillary personnel (teammates) have been implemented and documented.
d.The physician is provided information required for decision making; results of tests/treatments/consults are available in the record, key outcomes/progress is actively communicated to the physician.
e.The physician is prompted for orders when appropriate; orders for tests/treatments/interventions to clinically progress the patient, orders for tests/treatments/interventions to clinically prepare patient for discharge.
f.Physician communication is streamlined to minimize physician interruptions while ensuring timely attention to required interventions.
g.An anticipated discharge date is established by incorporating information from the physician to ensure completion of patient teaching, elimination of barriers, discharge instructions, readiness of discharge plan and compliance with payer requirements for discharge notices.
h.A discharge plan is ready for the patient when the patient is medically ready to transition to the next level of care.
i.Authorizations or referrals for further care have been obtained.
2.Leads daily CAPP (Communication and Patient Planning) rounds with interdisciplinary team members to review assigned population, ensure patient progression and identify barriers to discharge.
3.Assists in patient/family interview and/or care conferences.
4.Attends long-length of stay conferences and PCCS daily huddles.
5.Discharge Planning: Assesses and addresses discharge planning needs for assigned populations to include responses to receive consults and referrals, to ensure the patient is ready to transition to the next level of care when discharge is ordered by the physician:
a.Interviews the patient/family.
b.Develops and implements plans for any identified needs, ensuring:
i.Patient/family understanding and informed decision making to promote patient choice.
ii.Payer coverage of post-acute providers and services
iii.Connection of patient/family with available resources to assist with clinical/financial issues
iv.Compliance with legal requirements for issues such as adoption/guardianship/suspected abuse.
v.Compliance with Wayne UNC Utilization Review plan and regulatory guidelines.
c.Identifies and addresses potential issues with patient/family/physician discharge expectations.
6.Status Validation: Monitors patient status for assigned populations, to include initial status assignments and observation lengths of stay greater than 24 hours:
a.Collaborates with Access Nurses, Utilization Management department staff regarding status changes and verification.
7.Documentation: Provides timely and complete documentation of activities in the patient medical record:
a.Discharge plans and interventions
b.Care facilitation and coordination interventions.
8. Quality/Processing Improvement:
a.Captures data related to identified core measure, readmissions, and delays in discharge or services
b.Captures date to support workload and intervention metrics.
9. Facilitator:
a.Consults in the development of care paths, preprinted physician orders, patient/family education materials, and other tools to promote efficient and effective patient care
b.Collaborates with patient care nurse and interdisciplinary team
c.Participates in area specific committees, task forces and projects
d.Engages in area specific continual process review and improvement.
10. Change Agent
a.Maintains current knowledge of case management, discharge planning and medical social work through review of current literature, attendance and active participation in continuing education and professional organizations
b.Exhibits flexibility by managing multiple roles and responsibilities
c.Interoperates and communicates across multiple disciplines
d.Promotes a safe and health work environment.
11.The PCC is flexible to provide coverage in a department that operates seven days a week as needs arise. (i.e., may need to work weekends, holidays, and non-regular days.)

WAYNE

Other information:
Education
Graduate of an accredited program of professional nursing.
Bachelor's Degree in Nursing required.

Licensure/Certification
Current licensure to practice as a registered nurse in North Carolina. ACM-RN certification or equivalent preferred.

Experience
Minimum 3 years of applied clinical experience as a Registered Nurse.
Minimum 1 year hospital case management experience preferred.

Knowledge, Skills and Abilities
*General knowledge of the payor industry, resource management, reimbursement, discharge practices and evidence-based clinical practice is essential.
*Strong interpersonal and customer service skills.
*Ability to read, write and communicate effectively in English.
*Proficient with MS Office and EPIC, and the ability to learn new software rapidly.
*Flexibility to provide coverage in a department that operates 7 days a week as needs arise.

Valid NC Driver's License: No
If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.

PCC-622
01.8721.PCC-622.RN

Legal Employer: Wayne Health

Entity: Wayne UNC Health Care

Organization Unit: Care Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: WAYNE MED

Exempt From Overtime: Exempt: No