Care Coordinator, Remote, Wyoming (Remote/ RN/PT/OT/ST)
About the position Responsibilities • Serve as the link between patients and the appropriate health care personnel to ensure efficient, smooth, and prompt transitions of care. • Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays. • Review target outcomes and discharge plans with providers and families. • Complete all SNF concurrent reviews, updating authorizations on a timely basis. • Collaborate effectively with the patients' health care teams to establish an optimal discharge. • Assure patients' progress toward discharge goals and assist in resolving barriers. • Participate weekly in SNF Rounds providing accurate and up to date information to the H&C Transitions Sr. Manager or Medical Director. • Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services. • Engage with patients, families, or caregivers telephonically weekly and as needed. • Attend patient/family care conferences. • Assess and monitor patients' continued appropriateness for SNF setting according to CMS criteria. • Coordinate peer to peer reviews with H&C Transitions Medical Directors. • Support new delegated contract start-ups to ensure experienced staff work with new contracts. • Manage assigned caseload efficiently and effectively utilizing time management skills. • Enter timely and accurate documentation into coordinate. • Daily review of census and identification of barriers to managing independent workload and ability to assist others. • Review monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager to assist with the identification of opportunities for improvement. • Adhere to organizational and departmental policies and procedures. • Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws. • Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business. • Engage and collaborate with in-market leaders as needed based on current assignment or as directed by leadership. • Keep current on federal and state regulatory policies related to utilization management and care coordination. • Promote a positive attitude and work environment. • Attend H&C Transitions meetings as requested. • Perform other duties and responsibilities as required, assigned, or requested. Requirements • Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist. • May be required to pursue and maintain multi-state licensure to meet business needs. • 5+ years of clinical experience, in good standing with 1+ year of employment with H&C Transitions (1+ year of experience in Care Coordinator, Onsite role). Nice-to-haves • Experience working with the geriatric population. • Patient education background, rehabilitation, and/or home health nursing experience. • Familiarity with care management, utilization/resource management processes and disease management programs. • Proficient with Microsoft Office applications including Outlook, Excel, and PowerPoint. • Ability to prioritize, plan, and handle multiple tasks/demands simultaneously. • Detail-oriented. • Team player. • Exceptional verbal and written interpersonal and communication skills. • Solid problem solving, conflict resolution, and negotiating skills. • Independent problem identification/resolution and decision-making skills. Benefits • Comprehensive benefits package. • Incentive and recognition programs. • Equity stock purchase. • 401k contribution.