Coordinator Post Acute Care - Population Health

Summary:

The Post Acute Care Coordinator provides support for the Population Health Care Management Department and is instrumental in providing fully coordinated patient care to improve the overall care of patients who are part of the CHRISTUS Health value-based care ACO arrangements. As a member of the patient's multidisciplinary care team in the post-acute setting, the PA coordinator will facilitate communication between Agencies, Clinicians, RN Navigators, Care Coordinators, and Department leadership. They will support care transitions and post-acute care monitoring by making outreach calls to facilities, processing/importing incoming clinical documentation into the EMR, and facilitating coordination of care across the continuum. This role ensures seamless transitions of care and improves patient outcomes.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Retrieving PHI documents from internal Right Fax and secure email.
• Facilitates incoming Plan of Care and other documents to the appropriate clinician and/or Post-Acute Nurse Navigator (PANN). Distribute a Plan of Care in a timely and efficient manner to the PANN to ensure timely patient care and coordination of services.
• Respond to the home health agency regarding the status of the Plan of Care(s) by researching the status of the signed Plan of Care in the EMR and updating the home health agency.
• Supports Transition of Care programs by making timely telephonic outreaches to post-acute facilities to review/discuss expected discharge dates for those patients admitted to the facility; document findings in EMR.
• Coordinate receipt of pertinent clinical information order medical records from the facility, and notify the Transition of Care nurse of all confirmed patient discharges.
• Maintains the EPIC Post-Acute outreach report for post-acute admissions/discharges.
• Assist in the development and implementation of strategies to improve transitions of care and patient outcomes.
• Maintain accurate records and documentation in accordance with organizational policies and procedures.
• Participates in team meetings and contributes to the continuous improvement of the transitions of care and post-acute processes.
• Mails correspondence to high-risk and care coordination patients as needed to support RN Navigators and Care Coordinators.
• Demonstrates teamwork, takes initiative, and accepts other duties as assigned. Willingness and ability to learn new tasks.
• Prepares and runs operational reports e.g., productivity, utilization, etc.
• Has strong organizational and excellent oral communication skills.
• Able to work collaboratively with a multidisciplinary team.
• Able to work in a fast-paced, high-stress operation with high standards of excellence.
• Pay attention to detail when importing PHI documents in the EMR.
• Able to exercise proper phone etiquette with the ability to navigate proficiently through computer software systems.
• Other duties as assigned.

Job Requirements:

Education/Skills

• Associate or bachelor's degree preferred

Experience

• 2 years' experience in a healthcare setting required
• 2 years working with post-acute preferred
• Experience with EPIC and other electronic health records (EHR) systems required
• Must have practical experience with Microsoft Office applications

Licenses, Registrations, or Certifications

• None required

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time