Patient Care Planning
+ Contact: Samuel Serniak
+ Tel: 970-826-2468
+ Fax: 970-826-3179
+ Email: email@example.com
Craig, CO 81625
+ Position Purpose:
The Patient Care Planner is a support service of the Memorial Regional Hospital (MRH) that is committed to linking our patients to health care providers and resources within the community. The care planning / discharge planning process helps patients identify and access MRH and community resources with the goal of achieving improved and positive health outcomes. Through assessment, communication and coordination, the care planning process promotes and supports MRH's efforts to improve community health, facilitate individual case management, and health services integration. The Patient Care Planner, as member of the Population Health Management department, will help fulfill the Memorial Regional Health (MRH) mission of improving the quality of life for the communities we serve, with patient-centered care and service excellence.
Essential Functions and Basic Duties:
o Track patient cases from admission to discharge. Ability to identify patients who are likely to suffer adverse health consequences upon discharge, needing coordination of support services and follow-up care based on diagnosis and level of acuity.
o Conduct timely evaluations for all patients identified by their physicians, patient, nursing, family or friend request or discharge planner inquiry as needing discharge planning.
o Ability to develop individualized care plan for patients needing patient care planning support.
o Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care:
? From admission (regardless of status) ensures that patients are "pre-qualified" for hospital admissions.
? Continued admission (regardless of status) ensures that patients are "re-qualified" for hospital admissions.
? Conducts appeals on behalf of the patient and family (at time of service and for hospital stay denials).
? Develops discharge plans for patients to the most appropriate plans of care - understands the resources available and advocates for the patient for those resources.
o Understands Lifeline, Transition Care, Swing Bed, Home Health, Hospice, Nursing Home services, and can discern and explain which resource may be best for a specific patient based on diagnosis and level of acuity.
o Fully understands transitional care and how that service works with a Critical Access Hospital.
o Ability to advocate for patients, and negotiate with physician and ancillary staff for patients.
o Ability to advocate for patients with insurance companies and CMS for additional services.
o Expert at InterQual and/or Millimen clinical decision-support criteria.
o Able to identify patients at risk for abuse, depression, falls, or other conditions. Follow the proper procedures for reporting.
o Role requires staff member to be available for weekend Standby / Callback duty on a rotating schedule with other Patient Care Planners, within the hours of operation of insurance companies and CMS. Refer to MRH's Standby and Call Back Pay Policy for details.
o Assures that procedures and practices of the Population Health Management department conform to applicable accrediting, regulatory licensing and risk management standards, as provided for in the Hospital's Legal and Regulatory Compliance Program.
o Adhere to MRH standardized processes and procedures that create and support efficient and effective continuity of care practices for patients served by the care coordination team.
o Participate in the development of standardized processes and procedures that create and support efficient and effective continuity of care practices for patients served by the care coordination team.
o Participate in "outside the box" thinking and approaches for patients that could benefit from non-traditional treatment plans.
o Establish and maintain excellent working relationships with care coordination team members, patients and their families, providers and other medical personnel, community partners, other MRH staff, with an emphasis on building strong teams, improving processes, and providing excellent customer (patient) service.
o Assess and address barriers to care, including but not limited to: pre-authorizations, ability to pay, communication (non-English speakers, etc.), transportation, outside referrals.
o Ensure work is compliant with MRH policies, procedures, and quality measures.
o Serve as a liaison between clinic, hospital, and emergency department personnel, imaging, lab, dietary, pharmacy, specialty providers, patient billing advocates, third-party payers, community resources, and other agencies as needed in support of care coordination activities.
o Attend meetings to stay apprised of organizational communications. Notify the Director of Population Health Management or other senior leadership of staff concerns; participate in resolutions.
o Complete reports in a timely manner.
o Contribute to and participate in a collaborative, supportive environment among care coordination team members.
o Demonstrates 100% commitment to performing according to the CHOICE values of MRH and representing the organization in a positive and professional manner.
o Establishes and maintains effective communication and good working relationships with all co?workers.
o Adheres to MRH and department dress code policies and procedures.
o Utilizes initiative; strives to maintain steady level of productivity; self-motivated; manages activity and time.
o Completes annual education, training, in-service, and certification requirements; attends departmental staff meetings or reads meeting minutes.
o Maintains regulatory requirements.
o Maintains patient confidentiality at all times.
o Reports to work on time and as scheduled; completes work within designated times.
o Actively participates in departmental and facility performance improvement and continuous quality improvement activities.
o Strives to ensure continual compliance with departmental, hospital, state and federal regulations and policies.
o Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, public and staff.
o High School Diploma or GED
o Registered Nurse license in the State of Colorado
o Valid Driver's License
o Minimum 5 years of experience in an acute care setting
o Demonstrated success working in an integrated environment and working within a cross-functional team.
o Outstanding written and verbal communication, documentation, and presentation skills.
o Able to apply National Patient Safety goals to care and documentation.
o Knowledge of medical practices and patient care.
o Knowledge of patient examinations, diagnostic and treatment procedures.
o Ability to work with a Healthcare Electronic Medical Record to review patient data and run reports.
o Ability to communicate effectively, both in writing and orally.
o Ability to establish and maintain effective working relationships with employees at all levels throughout the institution.
o Ability to interpret, adapt, and apply guidelines and protocols.
o Ability to identify and resolve problems in a proactive, collaborative manner.
o Outstanding customer service skills.
o Demonstrated commitment and leadership ability to advance diversity and inclusion.
o Strong analytical skills, critical thinking, attention to detail and accuracy, and strong customer service skills.
Acute Care Hospital
o Fax Machine
o Copy Machine
o Basic Office Equipment
Mandatory Training & Involvement:
o SWANK Education
o Safety In-Service
o Annual Competencies
o NIMS Training: IS-100Hcb and IS-700A
o Staff Meetings
o Infection Control
o Hazardous Materials
o CHOICE Values
o AIDET + P
o LEAN training
o BLS Provider
The Memorial Hospital at Craig
Posted: over a month ago