Manager-Care CoordinationFacility: Mercy Medical Center Location: Rockville Centre, NY Department: Care Management Category: Nursing / Nursing Leadership Schedule: Full Time Shift: Evening shift Hours: 2:00PM-10:00PM ReqNum: 6017211
Graduate of an accredited school of nursing; Graduate of Bachelor's degree in nursing preferred.
Two to three years' experience in health care related discipline (hospital, agency, etc.) and/ or previous discharge planning experience and/or community health care experience preferred; must be extremely motivated, organized, flexible, and detail oriented. Excellent interpersonal skills (oral and written).
Ability to respond to short deadlines.
Effective problem solving abilities.
NYS RN license required; PRI and/or Screen certification preferred.
In collaboration with the HUB Manager of Care Coordination (MCC) ensure appropriate patient placement and level of care.
Utilizes Electronic charts and tools, EPIC, Midas, Milliman Guidelines (MCG) and Navi-Health (e-discharge) to monitor patient's progression of care through to discharge.
Works collaboratively with unit staff and Social Worker to progress each patient's case towards discharge.
Reviews daily patient's TLOS and DRG, updates EPIC as needed and prints TLOS report.
Leads SNAP/Interdisciplinary rounds/ huddles to drive patient progression, identifying barriers to discharge and align care team towards discharge goals.
Escalates all unresolved barriers, discharge concerns, and patients not meeting criteria to Director.
Checks MCG Discharge screen every three days to monitor patient's progression towards discharge.
Uses variances tracking in MCG to track delays to discharge.
Actively monitors patient care progression at all levels including Observation, Inpatient, and Emergency Room status for progression of care as appropriate.
Serves as a consultant and educator for Physicians, MLP's, RN's, and ancillary staff regarding patient status, placement, payor requirements and utilization of resources.
Reviews Physicians and MLP's admission order and validates status and level of care matches order.
Works with staff to communicate to the HUB MCC unit's status including discharges, transfers, downgrades and patient location.
Coordinates the patient's plan of care in conjunction with Physician, MLP's, and Primary Nurse for appropriate sequencing of care/ interventions.
Communicates with patient/family progression of care, expected discharge date, and any potential barriers to discharge.
Identify potential discharges and update patient's status and TLOS in EPIC.
Works with Primary Nurse and SW/Discharge Planner on patient's discharge needs and/or barriers to discharge.
In conjunction with the unit secretary identify patient's proposed testing schedule and communicates to the Service Coordinator.
Identifies opportunities to transition testing to the outpatient setting and escalate as appropriate.
Communicates to the care team patients that are readmission or at risk for readmission.
Issues IMM, Code 44, HINNs, and/or 24 Hour Discharge Notice as appropriate in a timely manner.
Obtain prior authorization/determine coverage for novel anticoagulants, high cost oral antibiotics, and other medications as appropriate.
Develops in conjunction with Social Work discharge plans that are responsive to patient/ family concerns, health care status, available resources, age-specific problems and diagnosis specific issues.
Assist with PRIs as required.