RN-Patient Care Coordinator-Case Management

UnityPoint Health Information

The Patient Care Coordinator (PCC) serves an integral role in the multidisciplinary effort to identify and deliver quality and cost efficient healthcare to patients. While the role is multifaceted, concentrated effort is given to the oversight and collaborative coordination of care and services for a defined patient population, ensuring that adequate discharge plans are in place, and completing utilization management and quality review activities. The PCC teams with Social Services in guiding these efforts. St. Luke's C.A.R.E delivery model (Continuity, Accountability, Relationship-based, Evidence-based) reflects a commitment to compassionate, competent care delivered by the interdisciplinary team. Care is provided through a therapeutic relationship with the patient and family. A spirit of inquiry is encouraged and supported. Evidence-driven protocols are utilized to assure reliable and consistent care. The PCC collaborates with members of the interdisciplinary team to achieve department and hospital goals related to coordination of care, reducing readmissions, and efficiency of the patient stay.

The PCC is unit based, providing oversight to a defined patient population. The PCC has established core functions of care coordination that are consistent across units; teamwork to manage care coordination needs across all units is an expectation. The PCC reports centrally to the Manager of Care Coordination.

Clinical Excellence

• Maintains knowledge of utilization management criteria and communicates with UM Coordinator to ensure medical necessity and appropriate patient class for hospital stay.
  • Assesses for level of care (LOC) and expected length of stay (LOS) for patients entering the health care setting using established criteria when appropriate.
  • Provides LOC and LOS coaching and guidance to providers in all health care settings when appropriate.
  • Ensures that ordered diagnostic tests, procedures, and treatments are pre-authorized based on payer requirements and scheduling is coordinated for efficiency.
  • Complies with changes in clinical practice and standards as a result of evidence based practice.
  • Participates in data collection when the opportunity is presented.
  • Supports/participates in interpretation of clinical literature and uses to validate and/or change clinical practice.
  • Maximizes positive financial outcomes for patients and hospital through record review and patient interviews and makes recommendations to ensure appropriate coordination of care, length of stay, discharge planning, and quality of care.
  • Collaborates with appropriate team members in planning and implementation of strategies to manage length of stay and prevent readmissions.
  • Encouraged to make and/or support process improvement in all sites of care through participation in shared governance and performance improvement activities at the department and hospital-wide level.
• Facilitates the coordination of care and services through assessment of patient needs and collaboration with the interdisciplinary team.
  • Assesses patient's clinical and psychosocial needs, identifies risk factors and develops plan based on identified needs.
  • Identifies needed interventions, and communicates and collaborates with physician and primary nurse to individualize plan of care to meet patient's needs.
  • Collaborates with patient, family and other members of the healthcare team to address patient needs related to care coordination.
  • Coordinates and facilitates interdisciplinary planning and communication through multidisciplinary rounds, care coordination rounds, complex care report, discharge huddles, and consistent communication with other members of the team.
  • Facilitates meetings with patients, their support systems, and providers to insure their participation in the plan of care and discharge planning.
• Coordinates and facilitates discharge planning through both initial and ongoing assessments of psychosocial, financial, cultural and family factors.
  • Collaborates with patient and significant others in developing an individualized discharge plan consistent with identified patient needs.
  • Ensures discharge planning process is implemented in a timely manner, communicated to members of the interdisciplinary team and documented in the medical record.
  • Researches and facilitates referral to appropriate agency and/or community resources in collaboration with the patient, family and interdisciplinary team.
  • Displays thorough and accurate documentation of assessments, interventions and plans related to care coordination and discharge planning.
  • Adheres to requirements of CMS, The Joint Commission and other payers related to coordination of care, discharge planning, patient interventions and documentation.
• The associate may be required to provide activities described above in a care coordination float role.
• The associate may provide care coordination activities for another unit in addition to his/her own when need arises.
• The associate may have additional patient population specific care coordination responsibilities (ie. Center for Women's and Children's Health)
• The associate may have additional responsibilities outside of the traditional care coordinator role that are skill set dependent (ie. prior-authorization activities)

• Successful completion of an accredited nursing program; Baccalaureate degree in nursing required
• The Patient Care Coordinator role is designed predominantly for an RN, although candidates with commiserate healthcare experience may be considered. Baccalaureate degree required
• Minimum of three years' experience in a clinical setting preferred, with recognized knowledge and expertise in caring for specific patient populations
• Must possess current licensure for profession in State of Iowa, if applicable.
• Use of usual and customary equipment used to perform essential functions of the position.