The Care Management Resource Coordinator supports the efforts of Social Work, Case Management and Utilization Management professionals by performing a wide range of administrative duties that promote a positive patient-family experience during hospitalization, facilitate safe and timely discharge of patients, and reduce risk of unfunded services or excessive cost to patients-families. The Resource Coordinator interacts directly with patients and families, other healthcare organizations and suppliers, and third-party payers. This position receives regular supervision of work activities from the Manager, Case Management and/or Manager, Social Services. This position does not supervise any other position.
- 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.
Supports Social Work activities
- a) Receives, evaluates and fulfills requests for local transportation vouchers, meal cards and other amenities.
- b) Receives, evaluates and fulfills requests for out-of-area transportation, including air travel and lodging.
- c) Receives, evaluates and facilitates requests for Ronald McDonald House services.
- d) Appropriately escalates requests that do not meet criteria to responsible social worker or manager.
- e) Faxes medical records and other documents, as directed by social workers, to law enforcement agencies, government agencies, and other healthcare organizations.
- f) Assists patients-families to schedule appointments with various agencies.
- g) Assists patients with documents or letters needed for FMLA, border crossing applications, school activity letters, and other social needs related to their care.
- h) Schedules care conferences.
- i) Maintains complete and accurate patient resource materials, including primary care providers by payer source (including free and low-cost clinics), WIC information, housing resources, and other social services. Provides resource information as requested by patients-families, social workers, and care team members.
- j) Obtains car seats.
- k) Answers Social Work phone line and retrieves voice mail messages. Takes appropriate and authorized actions or routes to Social Worker.
Supports Utilization Management activities
- a) Reviews and organizes materials faxed to department, prepares daily reports and other materials, and distributes/directs to appropriate Utilization Management nurse.
- b) Receives and reviews third-party payer requests for concurrent review and notifications of denied hospital days; routes to appropriate Utilization Management nurse.
- c) Answers Utilization Management/Case Management phone line and retrieves voice mail messages. Takes appropriate and authorized actions or routes to Utilization Management or Case Management nurse.
- d) Scans and uploads into the EMR and/or financial applications authorization and requests for concurrent and retrospective third-party utilization reviews.
- e) Enters authorization information in financial applications.
- f) Maintains reports of denied hospitalizations and hospital days, pending appeals, outcomes of appeals, and reasons for delayed discharges.
- g) Identifies, monitors and communicates trends with third-party payer denials of authorization requests to appropriate manager.
Supports Case Management activities
- a) Identifies and provides appeal rights letters to in-house Tricare and Medicare patients, and documents in log and the medical record.
- b) Verifies address and other demographic information for purposes of coordinating delivery of home needs and communication with families post-discharge.
- c) Identifies current home care service providers, and documents in the medical record for the Case Manager.
- d) Determines third-party payer coverage/benefits and obtains insurance pre-authorization for home health services, post-discharge medications, rehabilitative therapy, durable medical equipment, medical transportation, and other post-discharge needs.
- e) Facilitates arrangements for post-discharge needs, including scheduling services and coordinating availability of equipment/supplies and medications, under the direction of the Case Manager. Provides patient-family, Case Manager and clinical care team members with timely and accurate status of coordination of services, and documents information in the medical record. Appropriately escalates to responsible Case Manager and other care team members any situation/issue that poses a barrier to providing for complete and timely post-discharge needs.
- f) Monitors and determines bed availability at rehab facilities, other acute care hospitals, long-term care facilities, mental health facilities and other organizations. Determines third-party coverage/benefits and obtains authorization for transfer to other facilities; faxes medical records and coordinates transfer of patient under direction of the Case Manager. Appropriately escalates to responsible Case Manager and other care team members any situation/issue that poses a barrier to on-schedule transfer. Documents status and actions in the medical record.
- g) Coordinates peer-to-peer medical records with third-party payers and PCH providers.
- h) Conducts post-discharge follow-up calls to patients, and appropriately notifies Case Managers when intervention is needed.
Care Management Department support
- a) Understands and focuses on Hospital Revenue Cycle key performance indicators.
- b) Works collaboratively with team members and performs clerical cross-coverage where
Provides excellent customer service
- a) Responds to emails within 24 hours.
- b) Clear communication skills with all internal and external customers.
- c) Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.
- Performs miscellaneous job related duties as requested.