Cardinal Health Skilled Inpatient Care Coordinator in San Antonio PET, Texas

The Skilled Inpatient Care Coordinator (SICC) plays an integral role in the patient’s journey towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team. The SICC completes weekly nH predict assessments and engages the PAC inter-disciplinary care team providing them with the nH Outcomes Prediction (proprietary decision-support tool) to align expectations for discharge planning. The SICC engages both the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transition of care. By serving as the link between patients and the appropriate health care personnel, the SICC ensures that efficient, smooth, and prompt health care services will be delivered to the patient across the continuum of care, beyond a single episode of care and addresses the ongoing needs of the patient.

Responsibilities

  • This position is performed onsite or telephonically as directed by the manager.
  • Performs functional assessments of patients using clinical skills and proprietary decision-support tools upon admission to PAC and at weekly intervals and upon discharge.
  • The SICC provides the initial post SNF discharge follow up telephone call to ensure identified patients have transitioned to the next level of care with all ordered services, medications, follow up MD appointments and assesses need for continued telephonic follow up with referral to TCC (Transitional Care Coordinator) as appropriate based on clinical judgement.
  • Services are provided in a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services required to meet the patient’s health needs; using communication and available resources to promote quality, cost-effective outcomes.
  • Collaborate effectively with the patient’s interdisciplinary health care team to coordinate target length of stay and an optimal transition plan to the most appropriate setting. The health care team includes physicians, PAC discharge planners, referral coordinators, physical therapist, etc. The patient and caregiver are involved in the decision-making process to identify personal care/health goals and to minimize service fragmentation during care transition.
  • Assists the patient in meeting discharge readiness goals with regards to their overall well-being. Assesses the patient for post discharge needs and coordinates telephonic follow up as needed.
  • The SICC acts as an intermediary between the interdisciplinary care team to connect the patient to resources and additional services.
  • Consults with PAC interdisciplinary team and/or management to resolve any barriers in the patient’s movement along the continuum of care.
  • Utilizes knowledge of behavioral change science and principles to guide patient/caregiver interventions.
  • Addresses end of life issues including hospice and palliative care options.
  • Practices cultural competency with awareness and respect for diversity.
  • Provides evidence-based, condition-specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner.
  • Coordinates comprehensive post discharge health care services, support programs, and referrals to community-based services
  • Participates in SNF IDT (Interdisciplinary Teams Rounds) weekly providing accurate and up to date information to the naviHealth Management team.
  • Engages with patient, family or caregiver either telephonically or on-site weekly and as needed including attending patient/family care conferences.
  • Manages assigned caseload in an efficient and effective manner utilizing good time management skills.
  • Enters timely and accurate documentation into nH Coordinate application
  • Conducts daily review of census and identification of barriers to manage independent workload and ability to assist others
  • Reviews monthly readmission reports, and other reports as needed to assist with the identification of opportunities for process improvement.
  • Adheres to organizational and departmental policies and procedures.
  • Maintains confidentiality of all PHI information in compliance with HIPAA, federal and state regulations and laws.

General

  • Keeps current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies and benefits)
  • Pursues multi-state licensure to meet business needs
  • Adheres to organizational departmental policies and procedures
  • Adheres to all local, state and federal regulatory policies and procedures
  • Must promote a positive attitude and work environment
  • Attends naviHealth meetings as requested
  • Performs all other duties as assigned
  • Holds as confidential the patient’s protected health information as required by applicable laws, regulations, or agency/institution procedures.

Qualifications

  • Registered Clinician is a requirement of the role with preference for RN, PT, or OT credentials
  • Current active unrestricted clinical license required
  • Bachelor’s degree preferred
  • 3-5 years of clinical experience required
  • Case Management experience with CCM preferred
  • Patient education background, rehabilitation and/or home health nursing experience a plus
  • Experience working with geriatric population preferred
  • Exceptional interpersonal and communication skills
  • Strong problem solving, conflict resolution and negotiating skills
  • Proficient with Microsoft Office applications including Word, Excel and Power Point
  • Independent problemidentification/resolutionand decision-making skills
  • Detail oriented
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
  • Team player
  • Ability to travel in a local or regional market depending upon facility alignment
  • Ability to establish a home office work space
  • Ability to function independently and autonomously with excellent self-discipline.

About naviHealth

NaviHealth partners with health plans, health systems and post-acute providers to manage the entire continuum of post-acute care. We utilize evidence-based protocols to optimize care and bundled payment methodologies to align all stakeholders. The result: optimized care and outcomes, reduced inpatient days, reduced hospital readmissions, and increased patient satisfaction.

Physical Demands/Work Environment:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

  • Ability to mobilize to and within sites within a geographical area, including car transport.

  • Ability to manipulate laptop computer (or similar hardware) between office and site settings.

  • Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time.
  • Ability to communicate with Clients and team members including use of cellular phone or comparable communication device.
  • Ability to sit for an extended period of time (1-2) hours.

The above statements are intended to describe the general nature and level of work performed by personnel assigned to this classification. This description is not to be construed as an exhaustive list of all job duties performed by personnel assigned to this classification.

NaviHealth ™ is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.

Cardinal Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.