Post Discharge Coordinator, BPCIA
Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world class doctor close to where they live.
The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.
The Bundled Payments for Care Improvement Advanced (BPCIA) Post DC Coordinator supports functions to the Hospital Navigators. Support includes, but is not limited to, making follow up phone contacts, gathering pertinent patient information, and determining need for additional patient follow up for the 90 days post discharge from the hospital for BPCIA Patients. The BPCIA Post DC Coordinator will document results and report / escalate issues to the RN Navigator, RN Navigator Manager, or National Director as warranted.
- Conduct post-discharge phone calls for targeted discharges for Steward Risk patients.
- Ensure appropriate post-discharge appointments are scheduled; schedule as needed.
- Validate post-discharge services are in place; e.g., VNA, Elder Services, etc.
- Utilizing an algorithm, refer patient to appropriate care management programs as needed
- Escalates high risk members to appropriate management to establish preventative tactics to reduce utilization within the 90 day bundle period
- Collaborate with acute and post-acute staff to ensure communication and pertinent information is shared with key stakeholders e.g. faxing, emailing, calls for information, data gathering and researching etc.
- Document communications as required in Steward's Care Management System
- Other duties as assigned.
Education / Experience / Other Requirements
- College graduate preferred
Years of Experience:
- 1-3 years health care experience preferred
Work Related Experience:
- Working in Care Management or hospital environment preferred
- Medical terminology preferred
- Patient related call center acceptable
- Strong interpersonal skills
- Solid written and verbal communication skills
- Strong organizational skills
- Team oriented
- Ability to work semi-autonomously if needed
- Experience with Electronic Medical Record strongly preferred
- Experience with Microsoft Office (Word, Excel, etc.) preferred
Job Status: Full Time
Job Reference #: 9186