Care coordination is the deliberate organization of patient care activities to facilitate the appropriate delivery of health care services. This position provides comprehensive outpatient support for patients as assigned and uses bio-psychosocial assessments to develop patients plan of care. Develops, implements, monitors and documents the utilization of resources and progress of the patients care through advocating and facilitating options and services to meet the patients behavioral and health care needs. This position builds relationships with community partners and catalogs available resources to meet the needs of our patients and their families. This position may report to the Care Coordination Manager, the RN Care Manager Team Supervisor or Social Worker Team Supervisor.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- a) Assesses the patients biopsychosocial status, which may include, but is not limited to, available financial and community resources, parents / patients comprehension of medical conditions, mental health status, available support systems, safety issues, risk for abuse/neglect, suicide risk assessment, coping skills, cognitive abilities, etc. as requested by Case Manager or as determined by the Social Worker's professional judgment.
- b) Identify any barriers that impede treatment and/or recovery, provide information to the Interdisciplinary Care Team, and participate in proactive care planning.
- c) Identify resources to address family needs or care barriers to promote patient safety and well being, as well as optimize parent involvement in the patients care plan.
Documentation and Communication
- a) Completes clinical record documentation as required by departmental procedures in a timely manner.
- b) Cultivates and maintains effective interaction/communication with members of the interdisciplinary clinical care team and proactively engages patients and families in care coordination across the continuum of care.
- c) Participates in organizational and departmental operational initiatives to improve care delivery methods.
- a) Assists in development, implementation and revision of individual care plans in a manner that promotes sound financial stewardship and patient-family advocacy.
- b) Provides education regarding medical compliance, crisis intervention, support groups, etc.
- c) Identifies potential risk factors and barriers to care. Proactively collaborates with members of the interdisciplinary clinical care team to identify needs and documents a clear and comprehensive care plan to address risk factors and barriers to care.
- d) Assures proper care transitions by collaborating with hospital staff, PCCN physicians/providers, payers, referral coordinators, and various community services.
- e) Facilitates referrals and assistance to assist with timely access to providers. Monitors for appropriate follow-up.
- f) Advises families on available resources and programs through the educational system, such as 504s and IEPs and advocates on behalf of patients and families when necessary.
- a) Maintains professional competency by regularly participating in a variety of educational programs and in-services, reviewing relevant professional publications, participating in community based committees related to service line responsibilities, and/or participating in professional societies to ensure ongoing awareness of current methodologies, practices and philosophies as applied to the patient care population.
- b) Maintains current knowledge of community and other resource networks to meet patient and family needs, to provide relevant resources, and to assist as necessary, with connecting the patient/family to the relevant resources.
- a) Provides excellent customer service routinely in interactions with all customers, i.e. coworkers, patients, families, health plans, physicians, etc.
- b) Responds to email within 24 hours or one business day.
- Performs miscellaneous job related duties as requested.