Registered Nurse; RN-Acute Care - Care Coordination Team Lead

Hours:

FT Days Shift: M-F 8-5pm or 8:30-5:30pm Onsite interview Relocation assistance for eligible candidates

The Care Coordination Team Lead (CC TL) is responsible for development and mentoring of a care coordination team. The CC TL's function is to support the care coordinators and leadership team during the patient's acute hospitalization or in the ambulatory case management program, working with acute, chronic and long-term stages of illness for a defined patient population. The role includes critical patient assessment, transitional care planning, discharge planning, physical and psychosocial assessment, patient advocacy, education of the patient /family and monitoring quality indicators to demonstrate outcomes for the team resulting from the service provided.

The CC TL collaborates with interdisciplinary care team to provide a comprehensive assessment of the patient's plan of care, goal/outcome fulfillment and continued care needs. The CC TL provides hands on support to the team in their assigned area and is the first point of contact for team members. The CC TL may have responsibility for training new hires, overseeing floor / area workflow, and facilitate coverage for staff schedule.

Additionally, the CC TL may be required to work on process improvement projects with leaders, as well as, pulling data and metrics based on the team's performance to update dashboards and visual management lanes in the department

• Assessment – Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria. Factors assessed include support system, psychological, functional, socioeconomic, and cultural needs.
• Assesses insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers.
• Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.
• Strong assessment skills 15%
• Disposition Planning – Implements discharge planning and provides resource information in a timely and efficient manner.
• Identifies and documents barriers for timely disposition.
• Collaborates with the interdisciplinary care team in developing an appropriate transitional care plan.
• Provides education/counseling to patient/family in understanding, accepting, and following medical recommendations of his/her conditions.
• Understands eligibility processes and criteria for Local, State and Federal resources.
• Responds to referrals from hospital staff, physician offices, community, and family to provide resource information, and education when requested.
• Performs financial needs assessment for patients in need of assistance for follow-up care throughout the continuum.
• Provides follow-up for patients needing post-discharge assistance.
• Helps promote respect of cultural, ethnic, or religious beliefs to assist Care Coordinators develop an appropriate/comprehensive transitional plan to the next level of care.
• Effectively escalates issues to payers and other team members to help resolve delays in discharge related to post-acute authorizations.
• Engage patient, family and/or team members in discharge planning in those events where payor denial is received.
• Documentation – Record all assessments completed in the medical record.
• Document chart notes accurately and timely per departmental protocol in EPIC.
• Monitor for compliance of departmental documentation standard work 15%
• Team Lead Responsibilities – Oversight, coach, and mentor team utilizing evidence-based care coordination principles.
• Promotes a healthy work environment.
• Assist with department schedules and coverage plans (as required).
• Participate in the interviewing process with departmental leadership of potential team members.
• Provide precepting and education during the orientation process ensuring that new team members understand the care coordination functions and identifies any additional training needs.
• Provide feedback to assist in completing yearly performance evaluations for team.
• Assist in quality/safety and performance improvement activities for the team.
• Assist with ongoing training of new initiatives for the department along with departmental leadership.
• Help facilitate indigent patient contracts.

3 years recent Care…