Care Coordination Lead KHC

Facility: Kennestone Hospital

Job Summary:

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.

Core Responsibilities and Essential Functions:

4. Team Lead Responsibilities a. Oversight, coach, and mentor team utilizing evidence-based care coordination principles. b. Promotes a healthy work environment. c. Assist with department schedules and coverage plans (as required). d. Participate in the interviewing process with departmental leadership of potential team members. e. Provide precepting and education during the orientation process ensuring that new team members understand the care coordination functions and identifies any additional training needs. f. Provide feedback to assist in completing yearly performance evaluations for team. g. Assist in quality/safety and performance improvement activities for the team. h. Assist with ongoing training of new initiatives for the department along with departmental leadership. i. Help facilitate indigent patient contracts 1. Assessment a. 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. b. Assesses insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. c. Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution. d. Strong assessment skills. 2. Disposition Planning a. Implements discharge planning and provides resource information in a timely and efficient manner. b. Identifies and documents barriers for timely disposition. c. Collaborates with the interdisciplinary care team in developing an appropriate transitional care plan. d. Provides education/counseling to patient/family in understanding, accepting, and following medical recommendations of his/her conditions. e. Understands eligibility processes and criteria for Local, State and Federal resources. f. Responds to referrals from hospital staff, physician offices, community, and family to provide resource information, and education when requested. g. Performs financial needs assessment for patients in need of assistance for follow-up care throughout the continuum. h. Provides follow-up for patients needing post-discharge assistance. i. 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. j. Effectively escalate issues to payers and other team members to help resolve delays in discharge related to post-acute authorizations. k. Engage patient, family and/or team members in discharge planning in those events where payor denial is received. 3. Documentation a. Record all assessments completed in the medical record. b. Document chart notes accurately and timely per departmental protocol in EPIC. c. Monitor for compliance of departmental documentation standard work Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

Bachelor's Degree BSN from an accredited school of nursing Required or Master's Degree Master Social Work from an accredited school of social work. Required

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Lic Clinical Social Worker GA or Lic Master Social Worker GA or Master Social Worker or Reg Nurse (Single State) or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

BSN-currently licensed as a Registered Nurse in the State of Georgia or hold a privilege to practice in the State of Georgia under the Enhanced Nurse Licensure Compact (eNLC) Upon Hire Required or MSW, currently licensed as a Social Worker in the State of Georgia. Upon Hire Required and ACM or CCM upon hire or within 1 Year Preferred

Required Minimum Experience:

Minimum 3 years recent Care Coordination experience in a hospital setting. Required and Exposure to multiple medical populations Preferred

Required Minimum Skills:

Strong interpersonal skills. Excellent verbal and written communication skills. Competency and confidence with crucial conversations in high stress environment. Ability to organize and guide care coordination team functions, effectively coach, and lead change, perform critical analysis, promote patient/family autonomy and plan/organize efforts effectively for the continuum of care.