Clinical Care Coordinator-BH LIP

At Nuvance Health, we enjoy the benefits of a two-state system as we cultivate an inclusive culture where everyone feels welcomed, respected and supported. Together, we are a team of 15,000+ strong hearts and open minds. If you share our values of connected, personal, agile and imaginative, we invite you to discover what’s possible for you and your career.

Norwalk Hospital is a 366-bed academic and community medical center serving Fairfield County, Connecticut, and the surrounding New York Metro area. We are a Level II Trauma Center and Joint Replacement Center of Excellence, and we provide advanced cancer, heart, and neuroscience care.

Our accolades include the following:

• The Leapfrog Group - Grade A for quality and patient safety
• Health grades - America’s 50 Best Hospitals
• U.S. News & World Report - high performance in heart failure treatment

At Norwalk Hospital, we prioritize the health and well-being of our team, fostering a friendly and supportive culture where collaboration and compassion are at the heart of what we do. From the moment you step through our doors, you’ll experience a sense of community that makes our hospital a truly special place to work. Our employees feel a deep connection here because we’re not just part of the community – we are its center.

Performs crisis assessments and formulates continuity of care and/or discharge/transition plans in collaboration with patient, family and multidisciplinary healthcare team. Provides ongoing assessment, monitoring and evaluation to meet the individual needs of patients. Assists in resource management through facilitation of care and participation in program planning. Provides education to patients/families regarding coverage, care options and community resources.

• Social Work Clinical Care Coordinators provide clinical social work assessment and interventions which include counseling, bereavement and crisis intervention as well as assessment and intervention in cases involving complex family/patient dynamics.
• Coordinates multiple aspects of care to all appropriate patients to ensure the patient progresses through the course of treatment and/or hospitalization. Makes the transition to the next level of care with the services required to promote high-quality outcomes.
• Assists in the development of the patient's plan of care and ensures the plan is implemented timely. Discusses with the healthcare team identified delays while providing direction, assistance and support in developing strategies and interventions to move patient through the continuum of care. Follow up on any delays and help expedite diagnostics and treatments.
• Assesses patient's clinical readiness for transition in collaboration with the healthcare team and identifies available hospital and community resources based on the patient's clinical needs. Initiate paperwork for timely transfer of information to the community providers. Maintains easy flow of communication regarding patient's development and progress to all involved in care of patient.
• Maintains effective relationships and a positive outlook when interfacing with other departments, multidisciplinary healthcare team as well as patient's/families and community providers.
• Acts as an intermediary between patients, physicians and community providing advocacy, accurate healthcare information, potential referral services and proper treatment plans. Initiates and coordinates patient care conferences as required.
• Reviews all admissions and continued stays for assigned group of patients to determine certification to the assigned level of care utilizing standardized criteria to achieve optimal outcomes and reimbursements. Provides timely clinical information to the commercial insurers. Coordinates direct communication between MD's and insurers to proactively avoid denials. Identifies variances, avoidable days, readmission and LOS issues and works with department leadership and the healthcare team to develop changes in process to improve outcomes.
  
  Collaborates with other members of care coordination to communicate changes in level of care as well as other pertinent information required for an optimal…