Provides on-site operational supervision to Care Coordinators to assure quality and efficient service.
The Care Coordinator Lead is responsible for the achievement of optimal health for the patient, access to care and appropriate utilization of resources, balanced with the patient’s right to self-determination The Care Coordinator Lead, with respect to payer requirements, will ensure timely notification and communication of pertinent clinical data to support admission, clinical condition, continued stay and authorization of post-acute services.
ESSENTIAL FUNCTIONS OF THE JOB:
1. The Care Coordinator Lead will assess patients for clinical, psychosocial, financial and operational factors that may affect the progression of care. Using these criteria stratify patients at risk for over utilization of services and/or in need of care coordination services.
2. Collaborate with clinical team to reduce inpatient length of stay and reduce readmissions across the organization
3. Performs and documents appropriate admission and continued stay reviews using current InterQual/Milliman Care Guidelines criteria on assigned patients.
4. Based on the health care team's assessment, patient choice and available resources, develops an effective transition plan.
5. Actively participates in CTR rounds; interprets, and integrates the patient’s story into the overall multidisciplinary plan of care.
6. Develops and implements corrective action plans for resolution of complex problematic issues and elevates to management as necessary.
7. Documents appropriately per care coordination policy. Responsible for documenting information that is not duplicative but instead is complementary and contributes to the progression of the plan of care.
8. Collaborates with Physician Advisor for complex issues related to the medical plan of care.
9. Actively participates in clinical performance improvement activities as assigned.
10. Remains current on clinical practice and protocols impacting clinical reimbursement.
Utilization Management Lead Duties:
Inpatient Lead Duties: