Patient Care Coordinator (Healthcare)

Position Summary

The Patient Care Coordinator facilitates development, implementation, coordination and evaluation of patients interdisciplinary treatment plan. Collaborates with physician and interdisciplinary team to assure care is provided based on plan of care.

Essential Job Functions/Accountabilities

Focuses on early discharge planning. Collaborates with other disciplines (e.g. social work, home health, therapies, etc.) Establishes communication with key staff along continuum of care, including payers and payer information available preadmission. Connects patients current status compared to level of care criteria with payer information and communicates this information to utilization review. Refers cases to Social Work according to established criteria compared to patients assessment information and plan for appropriate follow-up care.

Assures comprehensive patient assessment occurs and documents findings in medical record and/or database as appropriate. Implements use of appropriate clinical pathway or interdisciplinary plan of care for patient, using pathway/plan and payer information as guide to patients care throughout the hospital stay. Participates in development and on-going assessment of patients interdisciplinary plan of care.

Assures appropriate level of care is provided, using established criteria as basis for decision making. Evaluates nursing care requirements and patients response to nursing intervention and medical therapies. Summarizes, communicates and acts as a resource when patient is transferred to another unit. Facilitates continuity with plan for patients care. Shares, guides and directs nursing team members regarding plan of care. Participates in patient care responsibilities based on clinical judgment.

Attends rounds with physician and other members of interdisciplinary team to include assessment of current discharge and treatment plans, intervening to prevent variances and continuing communication of patient and family needs. Records variances according to variance reporting system.

Works with patient and family, collaboration with physician, social worker and outside agencies for discharge planning and plans comprehensive teaching based on short term and long term goals. Arranges simple and complex home care for patients and families. Assures that patient meets discharge criteria. Acts as a resource during the period of time between patients discharge and first contact with next level of care (e.g. physicians office, home care visits, etc.).

Evaluate patients progress based on pathway and discharge planning goals and communicates this information to physician and other appropriate team members. Completes discharge instructions, medication reconciliations and other required home going paperwork; reviews instructions with the patient and assists the nursing team to promote timely discharges.

All other duties not specifically assigned.

Position Requirements

Education: Graduate of a school of Nursing. B.S.N. preferred.

Experience: Three (3) to Five (5) years recent experience providing nursing care relevant to patient population. One (1) to three (3) years of discharge planning or case management experience preferred.

Technical Skills: N/A

Certifications/Licenses/Registrations: Current license to practice as a registered nurse in the State of Ohio.