Care Coordinator- Care Management- PT- Days w/weekends

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Luminis Health
February 3, 2021
Annapolis, Maryland
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Care Coordinator- Care Management- PT- Days w/weekends

Job #: DEE-82746
Category: Nursing (RN/NP/CNM)
Location: Annapolis, MD
Posted Date: February 2, 2021








Position Objective:

Responsible for the assessment and coordination of patient care for the achievement of patient outcomes. Assesses, plans, implements, evaluates and coordinates patient care needs to facilitate the plan of care and timely discharge.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

  1. Completes assessment of patient's clinical course to provide ongoing patient care coordination, verify patient's need for acute hospital level of care and identify discharge planning needs. Assesses patient/family adaptation to illness/disability and capacity to provide for patient's care needs. Identifies obstacles to discharge; seeks peer and director consultation regarding problematic cases or cases demonstrating deviations from the plan of care.
  2. Develops and arranges discharge plans for patients discharged to home with home health, Hospice, home infusion and routine sub-acute and skilled nursing facility placements and completes all necessary paperwork. Refers patients with complex discharge or psychosocial needs to Social Work. Communicates with Placement Specialists to ensure safe and appropriate transfers to lower levels of care.  (Assisted Living, subacute, snfs etc).  Collaborates with physicians, nurses, and other disciplines involved with care of the patient to foster a coordinated approach to patient care. Responsible for communicating with physician regarding the medical plan of care, anticipated discharge, and consideration of alternative setting.
  3. Facilitates and impacts process issues to avoid delays in patient care. Collaborates with UM nurse to assess patient's clinical course and verify need for acute hospital level of care or medical stability for care at the next level. Intervenes with appropriate individuals/department regarding delays in service that may have an impact on quality of care and/or length of stay. Collaborates with UM nurse to identify factors contributing to delays in service or delayed discharge. Provide feedback to unit management regarding delays in patient care services.
  4. Prepare patients and families for transition from hospital to home or alternative setting. Involve patients in their discharge planning to encourage independence. Involve family in care while patient is in hospital to create realistic expectations for post-hospital care. Assure appropriate teaching is started.  Documentation will reflect plan of care to address post-hospital care needs and evidence of patient/family involvement in planning.
  5. Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient & family, family/social support systems, financial, economic, and discharge needs. Initiates referrals to disciplines as indicated.

Educational/Experience Requirements:

  • Graduate of an approved nursing program.
  • Five years of clinical nursing experience in an acute care hospital setting with prior utilization review/utilization management experience.

Required License/Certifications: 

  • Current licensure as a registered nurse by the Maryland Board of Nursing. Adherence to the credentialing requirements of AAMC as stated in the nursing bylaws.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands –

Medium work. Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.


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